State of Texas and Higher Education Employees & Retirees 2009 Benefits

FY 2009

State of Texas and Higher Education

Employees, Retirees and their Dependents

Summary of Benefits

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Fact Sheet (22 mb, PDF document

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Physician & Lab Services
Hospital Services
Extended Care Services
Other Medical Services

Behavioral Health
Prescription Drugs
Pharmacy Benefit
Exclusions

The following benefits are available at Scott & White Health Plan designated facilities when medical care is necessary and provided, authorized, ordered or arranged by your Group Physician.

Benefit Description	Member's Copayment FY2009
Physicians and Lab Services
Physician office visit Primary Care Physician	$30
Specialist office visit	$40
Routine physicals - One per plan year for adults: periodic for children, or as directed by the primary care physician	$30 or $40
Diagnostic x-rays, mammography, and lab tests	No Copayment
Immunizations - For children 0 to 6 years of age	No Copayment
Immunizations - For children 7 years and older, and adults	$30
Well woman exam - One per plan year	$30 or $40
Vision, speech, and hearing screenings - For all enrolled participants	$40
Speech and hearing testing (covered for all participants)	$40
Speech therapy and rehabilitative therapy, including physical and occupational therapy - Covered as any other illness and not subject to any maximum	$40
Allergy testing	$40
Allergy serum	50%
Allergy serum administration - When allergy shot is administered without an office visit	No Copayment
Routine eye exam - One per plan year	$40
Office surgery and procedures (all office surgeries, excluding vasectomies and tubal ligations)	$30 or $40
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	No Copayment
Family planning	$40
Vasectomy and tubal ligation	No Copayment
Infertility benefits Back to Top	50%
Hospital Services
Inpatient hospital - Semi-private room and board or intensive care units	$100 per day copayment per admission, 5 day maximum. $1500 maximum per person per year
Outpatient day surgery	$100
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.	No Copayment
Blood and blood products - Inpatient and outpatient	No Copayment
Private duty nursing - Based on medical necessity	No Copayment
Outpatient facilities, including pre-admission testing and/or treatment room	No Copayment
Emergency care - In-area and out-of-area covered at listed copayment. If hospitalized, copayment is waived.	$100
Urgent care - Includes physician’s after-hours care or at an urgent care facility Back to Top	$50
Extended Care Services (based on medical necessity)
Skilled nursing facility - Covered up to 60 days per plan year	No Copayment
Hospice care - Inpatient and outpatient	No Copayment
Home health	No Copayment
Private duty nursing Back to Top	No Copayment
Other Medical Services
Hearing aids - $500.00 per ear every 3 years (repairs not covered)	Plan pays $500 per ear every 3 years
Hearing aid batteries - Not subject to any maximum amounts	No Copayment
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.	$40
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.	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. Artificial organs (e.g. heart) not covered. Donor expenses are covered. Artificial organs (e.g. heart) not covered.	No Copayment (Hospital copayments will apply)
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 Back to Top	No Copayment
Behavioral Health
Inpatient mental health - Covered in full up to 30 days per plan year	$100 per day copayment per admission, 5 day maximum. $1500 maximum per person per year
Inpatient serious mental illness - Covered as any other illness	$100 per day copayment per admission, 5 day maximum. $1500 maximum per person per year
Inpatient chemical dependency - Covered as any other illness, based on medical necessity	$100 per day copayment per admission, 5 day maximum. $1500 maximum per person per year
Outpatient mental health - 25 visits per plan year	$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 Back to Top	$40
Prescription Drugs
Plan Year Deductible	$50 per member per plan year
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	$10/$25/$40
Up to a 30-day supply per prescription or refill of Maintenance medication	$15/$35/$55
Infertility drugs are paid at 50% copayment	50%
Up to a 30-day supply of insulin for one copayment	$10/$25/$40
Up to a 30-day supply of each diabetic oral agent for one copayment	$10/$25/$40
The supply of necessary disposable syringes for the insulin supply for one copayment	$25
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 Back to Top	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	$30/$75/$120
Oral contraceptives up to a 90-day supply for one mail order copayment	$30/$75/$120
Infertility drugs are paid at 50% copayment	50%
Up to a 90-day supply of insulin for one mail order copayment	$30/$75/$120
Up to a 90-day supply of each diabetic oral agent for one mail order copayment	$30/$75/$120
The supply of necessary disposable syringes for the insulin supply for one mail order copayment	$75
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	20%

Exclusions

Non-emergency Health Care Services that are not provided, ordered, prescribed, or authorized by a Group Physician or Referral Physician.
Cosmetic and reconstructive procedures undertaken to improve or modify a member's appearance, except for mastectomy reconstruction following breast cancer surgery.
Custodial or domiciliary care.
Artificial aids, corrective appliances, and medical supplies, except to the extent items shall be specifically listed as covered.
Services or supplies which are provided by an employer or governmental agency or entity.
Elective abortions, which are not necessary to preserve the health of the Member.
Experimental health care procedures.
In-vitro fertilization therapies or reversal of voluntary surgically-induced sterility.
Personal or comfort items during inpatient hospitalization.
Physical examinations and reports for employment, licenses, or insurance.
Psychological or other testing for educational purposes or services for non-medically necessary special education and developmental programs.

Cost of services in excess of the usual, customary, and reasonable charges.
In cases involving non-emergent treatments performed or prescribed by non-Health Plan providers, either inside or outside of the Service Area, and for which Health Plan has not authorized a referral, Health Plan will not cover any expenses associated with such treatments. In no event shall Health Plan cover any treatments which are excluded from coverage under this agreement.
Services for sex change operations or any related services.
Services covered under Worker's Compensation.
Experimental organ transplants and artificial organs.
Eyeglasses, contact lenses and any fitting charges.
Routine dental care.
Weight reduction programs, food supplements, services, supplies, surgeries including but not limited to gastric bypass, gastric stapling, vertical banding, or gym memberships, even if the participant has medical conditions that might be helped by weight loss; or even prescribed by a physician are not covered.