TRS-ActiveCare Plan Highlights

Transcription

1 TRS-ActiveCare Plan Highlights Effective September 1, 2018 through August 31, 2019 In-Network Level of Benefits1 Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug s, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network (after ) Out-of-Network (after ) Office Visit Diagnostic Lab Preventive Care See below for examples Teladoc Physician Services High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital (preauthorization required) (facility charges) Freestanding Emergency Room Emergency Room (true emergency use) Outpatient Surgery Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Annual Hearing Examination Preventive Care Routine physicals annually age 12 and over Mammograms 1 every year age 35 and over Smoking cessation counseling 8 visits per 12 months 14 Well-child care unlimited up to age 12 Colonoscopy 1 every 10 years age 50 and over Healthydiet/obesity counseling unlimited to Well woman exam & pap smear annually age 18 and over Prostatecancerscreening 1 per year age 50 and over Breastfeeding support 6 lactation counseling visits

2 Drug Deductible Short-Term Supply at a Retail Location 20% coinsurance after, except for certain generic preventive drugs that are covered at 100%. 2 $20 for a 1- to 31-day supply $20 for a 1- to 31-day supply 20% coinsurance after $40 for a 1- to 31-day supply 3 $40 for a 1- to 31-day supply 3 50% coinsurance after 50% coinsurance for a 1- to 31-day supply 3 50% coinsurance for a 1- to 31-day supply (Min. $65 4 ; Max. $130) 3 Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply) 5 20% coinsurance after $45 for a 60- to 90-day supply $45 for a 60- to 90-day supply 20% coinsurance after $105 for a 60- to 90-day supply 3 $105 for a 60- to 90-day supply 3 50% coinsurance after 50% coinsurance for a 60- to 90-day supply 3 50% coinsurance for a 60- to 90-day supply 3 (min. $180 4, max $360) 3 Specialty Medications (up to a 31-day supply) 20% coinsurance after 20% coinsurance 20% coinsurance (min. $200 4, max $900) Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) Tier 1 Generic Tier 2 Preferred Brand Tier 3 Non-Preferred Brand 20% coinsurance after 20% coinsurance after 50% coinsurance after $35 for a 1- to 31-day supply $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply $60 for a 1- to 31-day supply 50% coinsurance for a 1- to 31-day supply 3 What is a maintenance medication? Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes. When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply. A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. 1 Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. 2 For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the ($2,750 - individual, $5,500 - family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare. 3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 4 If the cost of the drug is less than the minimum, you will pay the cost of the drug. 5 Participants can fill 32-day to 90-day supply through mail order.

3 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Health Care Services Preventive Services Standard Lab and X-ray Disease Management and Complex Case Management Well Child Care Annual Exams Immunizations (age appropriate) Plan Provisions Annual Deductible Annual out-of-pocket maximum (including medical and prescription co-pays and coinsurance) Lifetime Paid Benefit Maximum Outpatient Services Primary Care 1 $1,000 Individual/ $3,000 Family $7,000 Individual/ $14,000 Family (includes combined Medical and RX copays, s and coinsurance) None $15 co-pay (First Primary Care Visit for Illness $0 2 ) Specialty Care $70 co-pay Other Outpatient Services 20% after 3 Diagnostic/Radiology Procedures Eye Exam (one annually) Allergy Serum & Injections Outpatient Surgery Maternity Care Prenatal Care Inpatient Delivery Inpatient Services Overnight hospital stay: includes all medical services including semi -private room or intensive care Diagnostic & Therapeutic Services Physical and Speech Therapy Manipulative Therapy 5 Equipment and Supplies Preferred Diabetic Supplies and Equipment Non-Preferred Diabetic Supplies and Equipment Durable Medical Equipment/ Prosthetics 20% after 20% after $150 co-pay and 20% of charges after $150 per day 4 and 20% of charges after $150 per day 4 and 20% of charges after $70 copay 20% without office visit $40 plus 20% with office visit $5/$12.50 copay; no 30% after Rx 20% after 16

4 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services Home Health Care Visit $70 co-pay Worldwide Emergency Care Nurse Advice Line Online Services After Hours Primary Care Clinics Ambulance and Helicopter Emergency Room 6 Urgent Care Facility go to $20 co-pay $40 copay plus 20% of charges after $250 copay plus 20% of charges after $50 copay per visit; does not apply Prescription Drugs (Group Value Formulary) Annual Benefit Maximum Rx Deductible Does not apply to preferred generic drugs Unlimited $150 Ask an SWHP Pharmacy representative how to save money on your prescriptions. Retail Quantity (Up to a 30-day supply) Maintenance Quantity BSW Pharmacies Only, including Mail Order (Up to a 90-day supply) Preferred Generic $5 copay $12.50 copay Preferred Brand 30% after Rx 30% after Rx Non-preferred 50% after Rx 50% after Rx Online Refills Mail Order Specialty Medications (Up to a 30-day supply) 1 Including all services billed with office visit 2 Does not apply to wellness or preventive visits 3 Includes other services, treatments, or procedures received at time of office visit 4 $750 maximum copay per admission and 20% after 5 35 max visit per year 6 waived if admitted within 24 hours Tier 1: 15% after Rx Tier 2: 15% after Rx Tier 3: 25% after Rx The SWHP MOMS Program provides you with professional staff who are notified of the delivery of your baby. These licensed professionals will contact you after you return home and help you with everything from the general well-being of both you and your baby, to breast/bottle feeding, to information on how to add your baby to your health plan. 17

5 Duncanville ISD Plan Year September 1, 2018 August 31, 2019 TRS Medical Insurance Rates include $271 district contribution. Monthly (12 pay) Employee Only $96.00 $ $ $ Employee + Spouse $ $1, $1, $1, Employee + Child(ren) $ $ $ $ Employee + Family $1, $1, $1, $1, Semi-Monthly (24 pay) Employee Only $48.00 $ $ $ Employee + Spouse $ $ $ $ Employee + Child(ren) $ $ $ $ Employee + Family $ $ $ $ pay Employee Only $64.00 $ $ $ Employee + Spouse $ $ $1, $ Employee + Child(ren) $ $ $ $ Employee + Family $ $ $1, $ *Please note the rates above are per paycheck and after the district has contributed. Split Rates (Employee + Family) Employee + Family $ $ $ $ Employee works for Duncanville ISD and their spouse works at another school district offering TRS-ActiveCare Medical. Pooled Rates (Employee + Family) Employee + Family $ $1, $1, $ Both employee and their spouse works for Duncanville ISD. 13