Scott & White Health Plan

Benefit Description

Member Pays
FY2012

Physicians and Lab Services

*Physician office visit Primary Care Physician (if applicable)

$25

*Specialist office visit

$40

*Routine physicals - One per plan year for adults: periodic for children, or as directed by the primary care physician (if applicable)

$25

*Diagnostic x-rays, mammography, and lab tests

20%

*Immunizations - For children 0 to 6 years of age

No charge

*Immunizations - For children 7 years and older, and adults

No charge

*Well woman exam - One per plan year

No charge

*Vision, speech, and hearing screenings - For all enrolled Participants

20% without office visit,
$40 plus 20% with office visit

*Colorectal Cancer Screening - subject to language in 13.4.13.2 of the Description of Benefits (zero cost sharing for certain preventive services under the Affordable Care Act)

No charge

No charge

Allergy testing

20%

Allergy serum

20%

Allergy serum administration - When allergy shot is administered without an office visit

20%

*Routine eye exam - One per plan year

$40

Office surgery and procedures (all office surgeries, excluding vasectomies and tubal ligations)

20%

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

$40 for first office visit

Family planning

$40

Vasectomy and tubal ligation

20%

Infertility benefits

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50%

Hospital Services

Inpatient hospital - Semi-private room and board or intensive care units

$150 per day copayment per admission, 5 day max. $2,250 max. per person per year plus 20%

Outpatient day surgery

$100 copayment plus 20%

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.

$150 per day copayment per admission, 5 day max. $2,250 max. per person per year plus 20%

Blood and blood products - Inpatient and outpatient

20%

Private duty nursing - Based on medical necessity

20%

Outpatient facilities, including pre-admission testing and/or treatment room

20%

Emergency care - In-area and out-of-area covered at listed copayment. If hospitalized, copayment is applied to hospital confinement.

$150 copayment plus 20%

Urgent care - Includes physician’s after-hours care or at an urgent care facility

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$50 copayment plus 20%

Extended Care Services (based on medical necessity)

Skilled nursing facility (based on medical necessity) - Covered up to 60 days per plan year

20%

Hospice care - Inpatient and outpatient (based on medical necessity)

20%

Home health

20%

Private duty nursing

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20%

Other Medical Services

Hearing aids (repairs not covered)

Plan pays $500 per ear every 3 years

Hearing aid batteries - Not subject to any maximum amounts

20%

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.

20%

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.

20%

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. Prosthetic devices, orthotic devices, and professional services related to the fitting and use of these devices are included, if services are pre-authorized and provided by a contracted provider.

20%

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. Donor expenses are covered. Artificial organs (e.g. heart) not covered.

$150 per day copayment per admission, 5 day max. $2250 max. per person per year plus 20%

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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20%

Behavioral Health Care Benefits

Inpatient mental health

$150 per day copayment per admission, 5 day max. $2250 max. per person per year plus 20%

Inpatient serious mental illness - Covered as any other illness

$150 per day copayment per admission, 5 day max. $2250 max. per person per year plus 20%

Inpatient chemical dependency - Covered as any other illness (based on medical necessity)

$150 per day copayment per admission, 5 day max. $2250 max. per person per year plus 20%

Outpatient mental health

$40

Outpatient serious mental illness - Covered as any other illness

$40

Outpatient chemical dependency - Same as any other illness and not subject to any maximums

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$40

Prescription Drugs 

Plan Year Deductible

$50

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.

Participating Retail Pharmacy - Tier 1, Tier 2, & Tier 3

Up to 30-day supply per prescription or refill of Non-Maintenance medication

$15/$35/$60

Up to a 30-day supply per prescription or refill of Maintenance medication

$20/$45/$75

Infertility drugs

50%

Up to a 30-day supply of insulin for one copayment

$15/$35/$60

Up to a 30-day supply of each diabetic oral agent for one copayment

$15/$35/$60

The supply of necessary disposable syringes for the insulin supply for one copayment

$35

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.

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20%

Mail Order Pharmacy - Tier 1, Tier 2, & Tier 3

Up to a 90-day supply per prescription or refill for one mail order copayment

$45/$105/$180

Oral contraceptives up to a 90-day supply for one mail order copayment

$45/$105/$180

Infertility drugs

50%

Up to a 90-day supply of insulin for one mail order copayment

$45/$105/$180

Up to a 90-day supply of each diabetic oral agent for one mail order copayment

$45/$105/$180

The supply of necessary disposable syringes for the insulin supply for one mail order copayment

$105

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.

20%