Benefit Description
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Member's Copayment
FY2010
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Physicians and Lab Services
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Physician office visit Primary Care Physician
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$30
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Specialist office visit
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$40
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Routine physicals - One per plan year for adults: periodic for children, or as directed by the primary care physician
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$30 or $40
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Diagnostic x-rays, mammography, and lab tests
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No Copayment
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Immunizations - For children 0 to 6 years of age
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No Copayment
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Immunizations - For children 7 years and older, and adults
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$30
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Well woman exam - One per plan year
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$30 or $40
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Vision, speech, and hearing screenings - For all enrolled participants
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$40
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Speech and hearing testing (covered for all participants)
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$40
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Speech therapy and rehabilitative therapy, including physical and occupational therapy - Covered as any other illness and not subject to any maximum
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$40
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Allergy testing
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$40
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Allergy serum
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50%
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Allergy serum administration - When allergy shot is administered without an office visit
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No Copayment
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Routine eye exam - One per plan year
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$40
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Office surgery and procedures (all office surgeries, excluding vasectomies and tubal ligations)
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$30 or $40
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Maternity care - Physician services, including diagnosis of pregnancy, pre- and post-natal care, and delivery (including delivery by C-section) - see “Hospital Services” for inpatient charges
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No Copayment
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Family planning
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$40
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Vasectomy and tubal ligation
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No Copayment
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Infertility benefits
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50%
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Hospital Services
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Inpatient hospital - Semi-private room and board or intensive care units
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$100 per day copayment per admission, 5 day maximum.
$1500 maximum per person per year
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Outpatient day surgery
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$100
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Other inpatient charges, including medically necessary surgical procedures. Includes orthognathic surgery. Guest trays, cots, telephone, maternity kits, paternity kits, and other personal items not covered.
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No Copayment
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Blood and blood products - Inpatient and outpatient
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No Copayment
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Private duty nursing - Based on medical necessity
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No Copayment
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Outpatient facilities, including pre-admission testing and/or treatment room
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No Copayment
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Emergency care - In-area and out-of-area covered at listed copayment. If hospitalized, copayment is waived.
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$100
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Urgent care - Includes physician’s after-hours care or at an urgent care facility
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$50
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Extended Care Services (based on medical necessity)
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Skilled nursing facility - Covered up to 60 days per plan year
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No Copayment
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Hospice care - Inpatient and outpatient
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No Copayment
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Home health
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No Copayment
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Private duty nursing
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No Copayment
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Other Medical Services
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Hearing aids - $500.00 per ear every 3 years (repairs not covered)
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Plan pays $500 per ear every 3 years
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Hearing aid batteries - Not subject to any maximum amounts
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No Copayment
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Dental - Restoration and correction of damage caused by external violent accidental injury to healthy, natural teeth, occurring while covered under the plan for services provided within 24 months of the date of the accident. Certain oral surgeries are covered.
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$40
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Durable Medical Equipment - Includes medically necessary purchase and/or rental. Benefits for rental are limited to, and will not exceed, the purchase price of the equipment. (Repairs are covered if not due to neglect or abuse.)
This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code.
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20%
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Prostheses - Artificial devices, surgical or non-surgical, which replace body parts, including arms, legs, eyes and cochlear implants are covered. Replacements and repairs are covered by medical necessity.
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20%
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Organ Transplants - Covered as any other illness for kidney, cornea, liver, heart, heart-lung, lung, pancreatic-kidney, bone marrow, and other organ transplants that the HMO determines to be not experimental and/or not investigational according to current medical plan guidelines. Artificial organs (e.g. heart) not covered. Donor expenses are covered. Artificial organs (e.g. heart) not covered.
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No Copayment
(Hospital copayments will apply)
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Ambulance - Professional local ground or air ambulance transportation services to the nearest hospital, appropriately equipped and staffed for the treatment of the participant’s condition
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No Copayment
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Behavioral Health
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Inpatient mental health - Covered in full up to 30 days per plan year
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$100 per day copayment per admission, 5 day maximum.
$1500 maximum per person per year
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Inpatient serious mental illness - Covered as any other illness
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$100 per day copayment per admission, 5 day maximum.
$1500 maximum per person per year
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Inpatient chemical dependency - Covered as any other illness, based on medical necessity
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$100 per day copayment per admission, 5 day maximum.
$1500 maximum per person per year
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Outpatient mental health - 25 visits per plan year
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$40
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Outpatient serious mental illness - Covered as any other illness
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$40
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Outpatient chemical dependency - Same as any other illness and not subject to any maximums
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$40
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Prescription Drugs
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Plan Year Deductible
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$50 per member per plan year
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If a brand name medication is dispensed when a Generic is available, member will be responsible for the Generic Copayment plus the cost difference between the Generic and the Brand Name medication.
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Participating Retail Pharmacy -Tier 1/Tier 2/Tier 3
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Up to 30-day supply per prescription or refill of Non-Maintenance medication
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$10/$25/$40
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Up to a 30-day supply per prescription or refill of Maintenance medication
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$15/$35/$55
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Infertility drugs are paid at 50% copayment
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50%
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Up to a 30-day supply of insulin for one copayment
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$10/$25/$40
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Up to a 30-day supply of each diabetic oral agent for one copayment
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$10/$25/$40
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The supply of necessary disposable syringes for the insulin supply for one copayment
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$25
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This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code. Up to a 30-day supply for a 20% copayment
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20%
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Mail Order Pharmacy -Tier 1/Tier 2/Tier 3
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Up to a 90-day supply per prescription or refill for one mail order copayment
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$30/$75/$120
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Oral contraceptives up to a 90-day supply for one mail order copayment
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$30/$75/$120
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Infertility drugs are paid at 50% copayment
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50%
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Up to a 90-day supply of insulin for one mail order copayment
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$30/$75/$120
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Up to a 90-day supply of each diabetic oral agent for one mail order copayment
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$30/$75/$120
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The supply of necessary disposable syringes for the insulin supply for one mail order copayment
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$75
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This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code. Up to a 90-day supply for a 20% copayment
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20%
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