Untitled Document [houstontx.gov]
|Medicare Advantage Plan Comparison Chart 2007 |
|Coverage |Medicare Advantage Plans |HMO Plan |Preferred Provider Organizatio |
| |Aetna |TexanPlus |
|What is the service |The Aetna PFFS is in all 50 |Brazoria, Chambers, Fort Bend, |Angelina, Brazoria, Cameron, |Plan covers all but 34 counties|All 50 states are in the service area. A reduced benefit and |
|area? |states. |Galveston zip codes: 77510, 77511,|Chambers, Fort Bend, Galveston|in the state of Texas. See the |higher deductibles apply for services obtained |
| | |77517, 77518, 77539, 77546, 77549,|zip codes: 77510, 77511, |HMO directory for a list of |out-of-network. To identify participating providers outside |
| | |77563, 77565, 77568, 77573, 77574,|77517, 77518, 77539, 77546, |counties in the service area, |of Texas, call 1-800-810-2583 or use your zip code to find a |
| | |77590, 77591, 77592, Harris, |77549, 77563, 77565, 77568, |or visit the Web site at |provider at . |
| | |Hardin, Jefferson County, Liberty,|77573, 77574, 77590, 77591, |. | |
| | |Montgomery County, Orange County |77592, Harris, Hardin, | | |
| | | |Hidalgo, Jasper, Jefferson, | | |
| | | |Liberty, Montgomery, | | |
| | | |Nacogdoches, Newton, Orange, | | |
| | | |Polk, Sabine. San Augustine, | | |
| | | |San Jacinto, Shelby, Tyler, | | |
| | | |Walker, Waller, Willacy | | |
|Does the plan cover |Yes. A member is covered for |Yes, but only in the event of a |Yes, but only in the event of |Yes, in the event of a medical |Yes, participants are covered at home or away, 24-hours a |
|participants out of |inpatient and outpatient |medical emergency. TexanPlus must |a medical emergency. Texas |emergency notify HMO Blue Texas|day, using their choice of physicians. A reduced benefit and |
|the service area? |emergency medical services |be notified as soon as possible. |HealthSpring must be notified |within 48 hours of initial |higher deductibles apply for services obtained |
| |that are furnished in and | |as soon as possible. |treatment. Seek services within|out-of-network. There is emergency care coverage outside of |
| |outside the Aetna Service Area| | |12 hours after the onset of an |the Continental United States. |
| |and worldwide. | | |illness or within 48 hours |To identify participating providers outside of Texas, call |
| | | | |after an accident. |1-800-810-2583. |
|What are the annual |None. |None. |None. |None. |Individual: $200 |Individual: $400 |
|deductibles? | | | | |Family: $600 |Family: $1,200 |
|Office Visits |• $15 for each primary doctor|• $10 for each PCP office visit |• $10 for each PCP office |$20 copayment for primary care |$30 copayment for primary |40% after annual deductible. |
| |office visits for |for Medicare-covered services. |visit for Medicare-covered |physician. |care physician. | |
| |Medicare-covered services. |• $25 for each specialist visit |services. |$45 copayment for specialist. |$50 copayment for specialist.| |
| |• $15 for each specialist |for Medicare-covered services. |• $25 for each specialist | | | |
| |visit for Medicare-covered | |office visit for | | | |
| |services. | |Medicare-covered services. | | | |
|Routine Physicals / |$0 for Preventive Care that |• $10 for each PCP office visit |• $0 for 1 annual routine | $0 copayment. One per 12 |$0 copayment. One per 12 |40% after annual deductible. |
|Checkups |includes routine physical, |and one routine physical exam |physical. |months. |months. | |
| |bone mass measurement, |annually for Medicare-covered |• $10 for each PCP office | | | |
| |colorectal screening exams, |services. |visit and one routine physical| | | |
| |prostate screening exam, |• $25 for each specialist visit |exam annually for | | | |
| |pelvic exam, mammography, pap |for Medicare-covered services. |Medicare-covered services. | | | |
| |smear, and Flu, pneumonia and |• $0 for a one-time physical exam|• $25 for each specialist | | | |
| |hepatitis vaccines. |within the first 6 months that you|office visit for | | | |
| | |have Medicare Part B, if your |Medicare-covered services. | | | |
| | |coverage began on or after 1/1/07.| | | | |
|Hospital Emergency |$35 for each outpatient |• $50 for each Medicare-covered |• $50 for Medicare-covered |$150 per visit (waived if |$150 copayment plus 20% for |$150 copayment plus 40% after |
|Room Charges per |emergency room visit. |emergency room visit; waived if |emergency room visit; waived |admitted to the hospital). You |emergency within 48 hours of |deductible for emergency after |
|visit? |The copayment is waived if the|admitted within 48 hours for the |if admitted within 3 days for |must notify your PCP or BCBS |accident/medical emergency. |48 hours of the |
| |patient is admitted to the |same condition. |the same condition. |within 48 hours. Physician’s |Illness anytime. Copayment |accident/medical emergency. |
| |hospital. |• NOT covered outside the U.S. |• World-wide emergency care. |office after hours: $20 per |waived if admitted to |Copayment waived if admitted to|
| | |except under limited |If you get inpatient care at a|visit. |hospital. |hospital. |
| | |circumstances. |non-plan hospital after your | | | |
| | | |emergency condition is | | | |
| | | |stabilized, your cost is the | | | |
| | | |cost sharing you would pay at | | | |
| | | |a plan hospital with plan | | | |
| | | |authorization. | | | |
|Urgent Care for Minor |$35 for each urgently needed |• $50 for each Medicare-covered |• $40 for each |Office Visits: $20 copayment. |Office Visits: $30 copayment.|Office Visits: 40% after annual|
|Emergencies |care visit. |urgently needed care visit. |Medicare-covered urgently |Urgent Care Center: $40 |Urgent Care Center: $60 |deductible. |
| | |• Copayment waived if admitted |needed care visit. |copayment. |copayment. |Urgent Care Center: 40% after |
| | |within 24 hours for the same |• Copayment waived if | |St. Lukes Minor Emergency |annual deductible. |
| | |condition. |admitted within 3 day(s) for | |Center requires $150 | |
| | |• Coverage available at any |the same condition. | |Emergency Room copayment. | |
| | |urgent care facility. NOT covered |• World-wide coverage. | | | |
| | |outside the U.S. except under | | | | |
| | |limited circumstances. | | | | |
|Ambulance Service |$15 for each Medicare-covered |$50 for each Medicare-covered |$100 for each Medicare-covered|$100 Copayment |Eligible expenses at 20% |Eligible expenses at 40% after |
| |one-way trip. |ambulance one-way service. |one-way ambulance service; you| |after annual deductible. |annual deductible is met. |
| | | |do not pay this amount if you | | | |
| | | |are admitted to the hospital. | | | |
|Inpatient Hospital |$0 per admission. |$300 for each Medicare-covered |• $275 for each |$500 copayment per hospital |20% after $500 copayment per |40% after $1,000 copayment per |
|Admissions | |stay in a network hospital. No |Medicare-covered stay in a |admission. Pre-authorization |admission. Pre-authorization |admission. Pre-authorization |
| | |copayment for additional days. |network hospital. No copayment|required. |required. |required. |
| | |Covered for unlimited days each |for additional days. Covered | | |$250 copayment for failure to |
| | |benefit period. |for unlimited days each | | |get pre-authorization. |
| | | |benefit period. | | | |
| | | |• If you are readmitted to | | | |
| | | |the hospital within 3 days for| | | |
| | | |the same diagnosis your | | | |
| | | |copayment will be waived. | | | |
|Outpatient Surgery |$0 for each Medicare-covered |$125 for each Medicare-covered |$200 for each Medicare-covered| $200 copayment for each |20% after annual deductible |40% after annual deductible for|
| |procedure. |visit or procedure to an |visit to or procedure in an |procedure. Pre-authorization is|for each procedure. |each procedure. |
| | |ambulatory. |ambulatory surgical center or |required. | | |
| | |$175 for each Medicare-covered |outpatient hospital facility. | | | |
| | |procedure in an outpatient | | | | |
| | |hospital facility. | | | | |
|Long-term acute care |Not Covered. |• $300 per LTAC admission for the|• $0 for 1-15 days |N/A |N/A |N/A |
|(LTAC) | |first 60 days of the LTAC |• $50 for 16+ days | | | |
| | |admission. (waived if LTAC | | | | |
| | |admission is a transfer from an | | | | |
| | |inpatient acute care setting). | | | | |
| | |• $228 per day for days 61-90 per| | | | |
| | |benefit period. | | | | |
| | |• $456 per each lifetime reserve | | | | |
| | |day (maximum 60 lifetime reserve | | | | |
| | |days). | | | | |
|Home Health |There is no copayment for |There is no copayment for |There is no copayment for |$20 copayment for each visit. |Skilled, non-custodial home |Skilled, non-custodial home |
| |Medicare-covered home health |Medicare-covered home health |Medicare-covered home health |Pre-authorization required. |health care services are 20% |health care services are 40% |
| |visits. |visits. |visits. | |after annual deductible. |after annual deductible. |
| | | | | |Limited to 60 visits per |Limited to 60 visits per |
| | | | | |calendar year. |calendar year. |
| | | | | |Pre-authorization required. |Pre-authorization required. |
|Hospice |Covered by Medicare in a |$0 copayment in a |$0 copayment in a |$0 copayment. Pre-authorization|Inpatient: Eligible expenses |Inpatient: Eligible expenses |
| |Medicare certified hospice. |Medicare-certified hospice |Medicare-certified hospice |required. Maximum calendar year|subject to $500 hospital |subject to $1000 Hospital |
| | |facility. |facility. |benefit is $20,000. |inpatient copayment and 20%. |Inpatient Copayment and 40%. |
| | | | | |Outpatient: Eligible |Outpatient: Eligible expenses, |
| | | | | |expenses, $30 copayment per |40% after deductible. |
| | | | | |visit. |Services other than those |
| | | | | |Services other than those |provided by hospice facility, |
| | | | | |provided by hospice facility,|such as attending physician’s |
| | | | | |such as attending physician’s|services, are subject to 40% |
| | | | | |services, are subject to 20% |after plan deductible. |
| | | | | |after the plan deductible. | |
|Skilled Nursing |• $0 per day for days 1-10 |• $0/day for day(s) 1 – 20 with |• $25/day for day(s) 1-100 |$25 per day. (Maximum of 60 |Eligible facility expenses |Eligible facility expenses |
|Facility |• $25 per day for days 11 – |immediate prior inpatient acute |for a stay in a skilled |days per calendar year.) |subject to $500 hospital |subject to $1,000 hospital |
| |20 |care. |nursing facility | |inpatient copayment: 20% |inpatient copayment; 40% |
| |• $50 per day for days 21 – |• $100/day for day(s) 21-100 |• No prior hospital stay is | |thereafter. Copayment waived |thereafter. Copayment waived |
| |100 |• $300/day for day (s) 1 – 20 |required. | |for transfer from inpatient |for transfer from inpatient |
| |• A prior hospital |• No prior hospital stay is |You are covered for 100 days | |hospital level of care to a |hospital level of care to a |
| |confinement is not required. |required. |each benefit period. | |skilled nursing level of |skilled nursing level of care. |
| |You are covered for 100 days |You are covered for 100 days each | | |care. |Services other than those |
| |each benefit period. |benefit period. | | |Services other than those |provided by skilled nursing |
| | | | | |provided by skilled nursing |facility, such as attending |
| | | | | |facility, such as attending |physician’s services, are |
| | | | | |physician’s services, are |subject to 40% coinsurance |
| | | | | |subject to 20% coinsurance |after the deductible. |
| | | | | |after the deductible. | |
| | | | | |Coverage is limited to the following conditions: If |
| | | | | |participant is not admitted to a skilled nursing facility and|
| | | | | |acute care hospitalization would be needed, the attending |
| | | | | |physician must order the care and the administrator must |
| | | | | |pre-authorized it. |
| | | | | |Coverage is also limited to a maximum of 60 days per calendar|
| | | | | |year. Custodial care or care for persistent illnesses and |
| | | | | |disorders that, in the administrator’s opinion, cannot be |
| | | | | |relieved or improved by medical treatment, are not covered. |
|Chiropractic Services |$15 for each Medicare-covered |$25 for each Medicare-covered | $25 for each Medicare-covered|$45 specialist copayment. No |Specialist Visit: 20% |Office Visit: 20% after annual |
| |visit (manual manipulation of |visit (manual manipulation of the |visit (manual manipulation of |maximum amount. |after $50 copayment. |deductible. |
| |the spine) |spine to correct subluxation). |the spine to correct | |Other Services: 20% |Other Services: 40% after annual |
| | | |subluxation). | |after annual deductible|deductible in outpatient setting. |
| | | | | |in outpatient setting. | |
| | | | | |Combined annual limit is $1,000 per calendar year, including |
| | | | | |all X-rays, lab, medicines, etc. |
|Inpatient Mental |$0 per admission. Combined |$300 for each Medicare-covered |$275 for each Medicare-covered|If admission is deemed |20% after $500 |40% after $1,000 copayment per |
|Health Services |maximum of 190 days per |stay in a network hospital. There |stay in a network hospital. |medically necessary, 100% after|copayment per |admission; 15 days maximum per |
| |lifetime for all inpatient |is a 190-day lifetime limit in a |There is a 190-day lifetime |20% copayment per admission. 30|admission; 30 days |calendar year. Pre-authorization |
| |mental health. Detoxification |psychiatric hospital. The benefit |limit in a psychiatric |days maximum per calendar year.|maximum per calendar |required. |
| |and rehabilitation for |days used under the Original |hospital. The benefit days |Pre-authorization required. |year. Pre-authorization| |
| |substance abuse treatment in a|Medicare program will count |used under the Original | |required. | |
| |Medicare-certified psychiatric|towards the 190-day lifetime |Medicare program will count | | | |
| |hospital. (Inpatient services |reserve days when enrolling in |towards the 190-day lifetime | | | |
| |in a general hospital have no |TexanPlus. |reserve days when enrolling in| | | |
| |maximum day limit.) | |Texas HealthSpring. | | | |
|Outpatient Mental |$25 for each Medicare-covered |For Medicare-covered mental health|For Medicare-covered mental |Office Visit: $25 copayment per|PCP Visit: 20% after |Office Visit: 40% after annual |
|Health Services |mental health visit |services, you pay $35/individual |health services, you pay |session. Maximum of 20 sessions|$30 copayment. 30 |deductible. 30 visits maximum per |
|Note: Emergency Room | |per visit and $20/group per |$25/individual per visit and |per calendar year. |visits maximum per |calendar year, includes outpatient |
|visits will require | |therapy visit. |$25/group per therapy visit. | |calendar year, includes|visits. |
|Emergency Room | | | | |outpatient visits. | |
|Copayment. | | | | | | |
|Chemical Dependency |Emergency Room: $35 for each |Emergency Room: $50 for each |Emergency Room: $50 for |Emergency Room: $150 copayment.|Emergency Room: 20% |Emergency Room: 40% after $150 |
|Services/Substance |Medicare-covered emergency |Medicare-covered emergency room |Medicare-covered emergency |Copayment waived if admitted. |after $150 copayment. |copayment and after deductible. |
|Abuse |room visit. The Copayment is |visit; waived if admitted within |room visit; waived if admitted|Office Visit: $20 copayment. |Copayment waived if |Copayment waived if admitted. |
| |waived if the patient is |48 hours. NOT covered outside the |within 3 days. Worldwide |Specialist Visit: $45 copayment|admitted. |Office Visit: 40% after annual |
| |admitted to the hospital. |U.S. except under limited |Emergency Care. |Inpatient: $500 copayment for |Primary Physician |deductible. |
| |Office Visit: $15 for each |circumstances. |Office Visit: $25 for each |each admission. Limited to 3 |Visit: 20% after $30 |Inpatient: 40% after $1,000 |
| |Medicare-covered visit |Office Visit: $35 per individual |individual/group therapy |series of treatments per |copayment. |copayment for each admission. |
| |Inpatient: $0 per admission |visit and $20 per group therapy |visit. |lifetime of individual. |Specialist Visit: 20% |Limited to 3 series of treatments |
| |Combined maximum of 190 days |visit for Medicare-covered |Inpatient: $275 for each |Pre-authorization required. |after $50 copayment |per lifetime of individual. |
| |per lifetime for all inpatient|services. |Medicare-covered stay in a | |Inpatient: 20% after |Pre-authorization required. |
| |mental health and |Inpatient: $300 for each |network hospital. Covered for | |$500 copayment for each| |
| |detoxification and |Medicare-covered stay in a network|unlimited days each benefit | |admission. Limited to 3| |
| |rehabilitation substance abuse|hospital. No copayment for |period. If readmitted to the | |series of treatments | |
| |treatment in a |additional days. Covered for |hospital within 3 days for the| |per lifetime of | |
| |Medicare-certified psychiatric|unlimited days each benefit |same diagnosis, copayment will| |individual. | |
| |hospital. |period. |be waived. | | | |
| |(Inpatient services in a | | | | | |
| |general hospital have no | | | | | |
| |maximum day limit.) | | | | | |
|Physical |$15 for each Medicare-covered |$25 for each Medicare-covered |$25 for each Medicare-covered |$45 specialist copayment per |Specialist visit: 20% |40% after deductible. Unlimited |
|Therapy/Outpatient |visit. |Occupational Therapy visit. |Occupational Therapy visit. |visit. Unlimited physical |after $50 copayment. |physical therapy visits that |
|Rehabilitation |Services include outpatient |$25 for each Medicare-covered |$25 for each Medicare-covered |therapy visits that continue to|Outpatient: 20% after |continue to meet or exceed treatment|
| |physical therapy, occupational|Physical Therapy and/or |Physical Therapy and/or |meet or exceed treatment goals |deductible |goals set by physician. For |
| |therapy, speech and language |Speech/Language Therapy visit. |Speech/Language Therapy and |set by physician. For |Unlimited physical |physically disabled persons, |
| |therapy | |cardiac rehabilitation visits.|physically disabled persons, |therapy visits that |treatment goals may include |
| | | | |treatment goals may include |continue to meet or |maintaining function or preventing |
| | | | |maintaining function or |exceed treatment goals |or slowing further deterioration. |
| | | | |preventing or slowing further |set by physician. For |Pre-authorization required. |
| | | | |deterioration. |physically disabled | |
| | | | |Pre-authorization required. |persons, treatment | |
| | | | | |goals may include | |
| | | | | |maintaining function or| |
| | | | | |preventing or slowing | |
| | | | | |further deterioration. | |
| | | | | |Pre-authorization | |
| | | | | |required. | |
|Durable Medical |15% of the cost for each |10% of the cost for each Medicare-|10% of the cost for each |Eligible expenses covered with |Eligible expenses are |Eligible expenses are 40% after |
|Equipment |Medicare-covered item |covered item. |Medicare-covered item. |20 percent copayment for rental|20% after annual |annual deductible for rental or |
| | | | |or purchase (initial placement |deductible for rental |purchase (initial placement only) of|
| | | | |only) of such equipment when |or purchase (initial |such equipment when pre-authorized |
| | | | |pre-authorized and determined |placement only) of such|and determined to be medically |
| | | | |to be medically necessary by |equipment when |necessary by BCBS. Coverage is |
| | | | |BCBS. Rental or purchase is |pre-authorized and |limited to equipment listed in the |
| | | | |determined by BCBS. Coverage is|determined to be |Health Care Finance Administration |
| | | | |limited to equipment listed in |medically necessary by |Coverages Issue Manual. Covers |
| | | | |the Coverages Issue Manual. |BCBS. Coverage is |hearing aid benefit of $1,000 per |
| | | | |Covers hearing aid benefit of |limited to equipment |36-month period. |
| | | | |$1,000 per 36-month period. |listed in the Health | |
| | | | | |Care Finance | |
| | | | | |Administration | |
| | | | | |Coverages Issue Manual.| |
| | | | | |Covers hearing aid | |
| | | | | |benefit of $1,000 per | |
| | | | | |36-month period. | |
|Diabetic Equipment, |Diabetic self-monitoring |Diabetic self-monitoring training:|Diabetic self-monitoring |Diabetic equipment: 20% of |Eligible expenses at |Eligible expenses at 40% after |
|Self-Monitoring and |training: $0 copayment |$0 copayment |training: $0 copayment |eligible charges |20% after $30 |deductible is met. Diabetic |
|Training Supplies |Diabetic equipment: $0 of |Diabetic equipment: 10% of |Diabetic equipment: 10% of |Diabetic supplies: same as |copayment. |equipment, self-management training |
| |eligible charges |eligible charges |eligible charges |prescription drug coverage |Diabetic equipment, |and supplies are covered on the same|
| |Diabetic supplies: $0 of the |Diabetic supplies: 10% of the cost|Diabetic supplies: 20% of the |Diabetes Self-Management |self-management |basis as benefits are provided for |
| |cost for each covered item |for each covered item |cost for each covered item |Training Programs: $0 copayment|training and supplies |treatment of other analogous chronic|
| |Injectable insulin (31-day |Injectable insulin (31-day |Injectable insulin (30-day | |are covered on the same|medical conditions. Also covered: |
| |supply): |supply): |supply): | |basis as benefits are |disposable or consumable outpatient |
| |• $10 generic |• $10 generic |• $10 generic | |provided for treatment |diabetic supplies, equipment and |
| |• $30 brand |• $30 brand |• $30 brand | |of other analogous |supplies that do not require a |
| |• $45 non-preferred | | | |chronic medical |prescription under state law, and |
| | | | | |conditions. Also |injectable insulin. |
| | | | | |covered: disposable or | |
| | | | | |consumable outpatient | |
| | | | | |diabetic supplies, | |
| | | | | |equipment and supplies | |
| | | | | |that do not require a | |
| | | | | |prescription under | |
| | | | | |state law, and | |
| | | | | |injectable insulin. | |
|Lab & X-rays |• $15 per visit for diagnostic|• $0 for specimen drawing or each |• $0 for specimen drawing, lab|$0 copayment. Included in |Office Visit: $30 |40% after annual deductible. |
| |laboratory, X-Ray, and nuclear|covered laboratory service |service |physician’s office visit. |copayment | |
| |testing |• $75 for each MRI, MRA, CT Scan |• $25 for each | |Outpatient: $0 | |
| |• $15 for each PET Scan |• $100 for each IMRT |Medicare-covered radiation | |copayment includes | |
| |• $15 for each CAT Scan |• $150 for each PET Scan |therapy | |independent lab and | |
| |• $15 for each MRI |• $25 for each Medicare-covered |• $0 for each Medicare-covered| |x-ray. | |
| |• $15 for each visit for |radiation therapy |X-ray visit in the physician’s| | | |
| |outpatient chemotherapy, |• $0 for each Medicare-covered |office or freestanding | | | |
| |dialysis and radiation |X-ray visit in the physician’s |facility | | | |
| | |office or freestanding facility |• $150 for each PET scan | | | |
| | | |• $100 for each MRI, CT or | | | |
| | | |cardiac nuclear medicine scan | | | |
|Bone Mass Measurement |$0 copayment |$0 copayment |$20 copayment - Primary Care |$30 copayment - Primary|40% after annual deductible is met. |
| | | |Physician visit |Care Physician visit | |
| | | |$45 copayment - Specialist |$50 copayment - | |
| | | |visit |Specialist visit | |
|Colorectal Cancer |$0 copayment |$0 copayment for age 50 and older: |$0 copayment for age 50 and |$0 copayment for age 50|40% after annual deductible for age |
|Screening (Includes | |• Flexible sigmoidoscopy – every 48 months. |older or members with risk |and older or members |50 and older or members with high |
|fecal | |• Fecal occult blood test-every 12 months. |factors: |with high risk factors:|risk factors: |
|occult blood test, a | |• Member with risk factors: Colonoscopy every 24 months. |• Fecal occult blood test |• Fecal occult blood |• Fecal occult blood test – every |
|flexible sigmoidoscopy| |• Member with low risk factors: Colonoscopy every 10 years. |–every year |test – every year. |year. |
|and colonoscopy) | | |• Flexible sigmoidoscopy -every|• Flexible |• Flexible sigmoidoscopy –every 5 |
| | | |5 years. |sigmoidoscopy – every 5|years. |
| | | |• Colonoscopy –every 10 years. |years. |• Colonoscopy –every 10 years. |
| | | | |• Colonoscopy –every 10| |
| | | | |years. | |
|Routine Immunizations |$0 per visit |• $0 copayment for the Pneumonia and Flu vaccines. |$0 copayment if service |$0 copayment to age 6. |$0 copayment to age 6. After age 6, |
| |Copayment is waived for |• No referral necessary for Pneumonia and Flu vaccines. |provided during an office visit|After age 6, $30 |40% after annual deductible when |
| |immunizations for flu, |• $0 copayment for the Hepatitis B vaccine. |when recommended by the |copayment when |recommended by the American Academy |
| |pneumonia, and Hepatitis B. | |American Academy of Pediatrics |recommended by the |of Pediatrics and U. S. Public |
| | | |and U. S. Public Health |American Academy of |Health Service. |
| | | |Service. Otherwise a $20 |Pediatrics and U. S. | |
| | | |copayment applies. |Public Health Service. | |
|Well-Woman Exam |$0 copayment |• $0 copayment for Medicare-covered screening: pap smear, breast|$0 copayment (One exam per 12 |$0 copayment. (One exam|40% after annual deductible. (One |
|(Includes clinical | |exam or pelvic exam every 24 months. |months). |per 12 months). |exam per 12 months). |
|breast exams, | |• Age 40 and older: Breast exam or mammogram every 12 months. |Mammogram-over age 40 or family|Mammogram-over age 40 |Mammogram-over age 40 or family |
|mammogram, pelvic exam| |• Members with high risk cervical cancer factors and are of |history of breast cancer |or family history of |history of breast cancer exists. |
|& pap smear) | |childbearing age: Pap smear every 12 months. |exists. |breast cancer exists. | |
| | |• No referral necessary for Medicare-covered screenings | | | |
| | |performed by a network provider. | | | |
|Well-Man Exam – |$0 copayment |$0 copayment for Medicare-covered exams |$0 copayment for |$0 copayment- one exam per 12 |$0 copayment-every 12 |40% after annual deductible –every |
|Prostate Cancer | |once every 12 months. |Medicare covered exams |months. |months. (includes |12 months. (includes members age 40 |
|Screening for age 50 | | |once every 12 months. |(includes members age 40 with a|members age 40 with a |with a family history of prostate |
|and older. (Includes | | | |family history of prostate |family history of |cancer or prostate cancer risk |
|prostate examination &| | | |cancer or prostate cancer risk |prostate cancer or |factors) |
|prostate specific | | | |factors) |prostate cancer risk | |
|antigen test) | | | | |factors) | |
|Prescriptions |RETAIL |RETAIL |
|If physician |Copayment for a 31-day Supply |Copayment for a 30-day Supply |
|prescribes or allows a|$10 – Generic |$10 – Generic |
|generic drug, but the |$30 – Preferred Brand |$30 – Preferred Brand |
|patient requests |$45 – Non-preferred Brand |N/A – Non-preferred Brand |
|brand, the copayment |$45 – Specialty Drugs |$45 – Specialty Drugs ( Prior authorization required) |
|will be the difference|MAIL ORDER |MAIL ORDER |
|between the cost of |Copayment for a 90-day Supply |Copayment for a 90-day Supply |
|brand and generic plus|$20 – Generic |$20 – Generic |
|the generic copayment.|$60 – Preferred Brand |$60 – Preferred Brand |
|For all plans you must|$90 – Non-preferred Brand |$0 – Non-Preferred Brand |
|use a designated |$90 – Specialty Drugs |$90 – Specialty Drugs (Prior authorization required) |
|retail or mail-order | | |
|pharmacy. | | |
|Vision Services |• $0 for 1 routine exam per |Features: |Features: |Vision screenings $0 |Features: |Features: |
| |calendar year |• $25 for each routine eye exam, |• $0 copayment for |copayment for Primary Care |• Vision screenings at $30 |• Eligible expenses are 40% after |
| |• $15 for each diagnostic |limited to 1 exam every year. |Medicare-covered eye |Physician - coverage for |copayment when performed by |annual deductible when performed by |
| |vision exam |• $25 for annual glaucoma screening for|wear (one pair of |members under age 18. |primary physician or $50 |physician. |
| |• $0 for post-cataract surgery|high risk patients |eyeglasses or contact |Features for all HMO |when performed by a | |
| |eyeglasses lenses and/or |• $25 for symptomatic ophthalmologic |lenses after each |members: |specialist for members under| |
| |contact lenses (Limited to the|services |cataract surgery) |• $3 copayment for routine|age 18. | |
| |Medicare allowable amount) |• $0 post-cataract surgery eyeglass |• $25 for each |eye exam every 12 months | | |
| | |lenses and/or contact lenses requiring |Medicare-covered eye |• Copayments for frames | | |
| | |intraocular lenses |exam (diagnosis and |and lenses are based on fee| | |
| | |• $50 for eyeglass frames after each |treatment for diseases |schedule. | | |
| | |cataract surgery requiring intraocular |and conditions of the | | | |
| | |lenses. |eye) | | | |
| | | |• $25 for annual | | | |
| | | |glaucoma screening for | | | |
| | | |high-risk patients. | | | |
| | | | |Davis Vision Value - Added Discount Program is offered to all members. There are discounts on|
| | | | |all vision services, a mail-order contact lens replacement program and discounts on laser |
| | | | |vision correction. |
|Hearing Services |$0 for 1 routine exam per |• $25 for each Medicare-covered |• $25 for each |Hearing screenings $0 |Hearing screenings at $30 |Eligible expenses at 40% after |
| |calendar year |Specialty Care Physician hearing exam |Medicare-covered hearing|copayment for Primary Care |copayment when performed by |annual deductible when performed by |
| |$15 - for each diagnostic |(diagnostic hearing exams). |exam (diagnostic hearing|Physician visit - coverage |primary physician for |physician. |
| |hearing exam |• Member pays pay 100% for routine |exams). |for members under age 18. |members under age 18. |Not covered: Exams for hearing aids,|
| |Hearing Aid |hearing exam and hearing aids. |• Member pays 100% for |One audiometric exam to | |hearing, speech, etc. |
| |Aetna PFFS will reimburse $500| |routine hearing exams. |determine type and extent |Not covered: Exams for | |
| |for hearing aids every 36 | | |of hearing loss once every |hearing aids, hearing, | |
| |months. | | |36 months. |speech, etc. | |
| | | | |Plan pays $1,000 for | | |
| | | | |hearing device once every | | |
| | | | |36 months. | | |
|Transplants |$0 for each admission |• $912 copayment per confinement (then |• $952 copayment per |PCP office: $20 copayment |Primary Doctor’s office: $30|Doctor’s office: 40% after annual |
| |For all other transplant |100% coverage up to 60 days) |confinement (then 100% |Specialist: $45 copayment |copayment |deductible |
| |services (i.e. outpatient |• $228 additional copayment per day |coverage up to 60 days) | |Specialist: $50 copayment |Outpatient facility: 40% after |
| |diagnostic, lab, X-ray, |(then 100% coverage for 61-90 days) |• $238 additional |Outpatient facility: $200 |Outpatient facility: 20% |annual deductible |
| |outpatient physician visits, |• $456 additional copayment per each |copayment per day (then |copayment |Inpatient facility: 20% |Inpatient facility: 40% after $1,000|
| |etc.) the member’s copayment |lifetime reserve day (then 100% coverage|100% coverage for 61-90 |Inpatient facility: $500 |after $500 copayment |copayment |
| |is based on the type of |for maximum 60 lifetime reserve days) |days) |copayment | | |
| |service provided. | |• $476 additional | | | |
| | | |copayment per each | | | |
| | | |lifetime reserve day | | | |
| | | |(then 100% coverage for | | | |
| | | |maximum 60 lifetime | | | |
| | | |reserve days) | | | |
|What is the annual |No annual out of pocket |Individual: $1,500 |Individual: $1,500 |Individual: 3,000 |Individual: $5,000 |
|maximum out-of-pocket |maximum |The following services apply: |Family: $3,000 |Family: $6,000 |Family: $10,000 |
|amount that I will | | |Excluding copays for |Copayments are always |Copayments are always payable. |
|pay? | |These out-of-pocket costs do not apply: |prescription drugs, |payable. | |
|What are the annual | | |inpatient mental health and| | |
|combined coinsurance/ | | |other supplemental riders | | |
|deductible maximum for| | |(e.g. Vision care, | | |
|the PPO? (Add all | | |prescription drug and | | |
|coinsurance, | | |durable medical equipment).| | |
|deductibles and | | | | | |
|eligible copayments) | | | | | |
|For Aetna PFFS, you | | | | | |
|will always pay the | | | | | |
|copayments listed in | | | | | |
|the chart. | | | | | |
| | | | | | |
|After I reach my |Yes. You will always pay the |Yes. You will always pay the copayments |Yes. You will always pay|Yes. You will always pay |Yes. You will always pay the|Yes. You will always pay the |
|annual out- of-pocket |listed copayments for medical |for outpatient prescription drugs and |the copayments for |the copayments or |copayments for physician |copayments for physician office |
|maximum, will I |services, prescription drugs, |PCP/specialist visits and any other |outpatient prescription |coinsurance for |office visits, prescription |visits, prescription drugs, |
|continue to pay any |and equipment. |services not listed above. |drugs and PCP/specialist|prescription drugs and |drugs, inpatient hospital |inpatient hospital stays, urgent |
|coinsurance or | | |visits and any other |vision care, durable |stays, urgent care and |care and emergency room services. |
|copayments? | | |services not listed |medical equipment and |emergency room services. | |
| | | |above. |inpatient mental health. | | |
|May plan participants |Yes. You may receive services|• You must go to network doctors, specialists, and hospitals. |Plan participants may |Plan participants may choose|Participants may select the |
|select physicians, |from any provider eligible to |• You must choose a primary care physician (PCP). |choose primary care |physicians, hospitals, |provider, hospital or pharmacy of |
|specialists, and |receive Medicare |• All care must be coordinated by your PCP. |physicians (PCP) and |pharmacies and other medical|their choice. If the provider is not|
|hospitals of their |reimbursement and who accepts |• PCP must refer you to other providers and specialists who are |pharmacies that are in the |providers that are members |in the PPO network, the doctor may |
|choice? |the plan. |in the same group. |HMO network. All care must |of the PPO network. Contact |be a ParPlan provider contracted |
| |The plan recommends you select|• Referral needed to go to network hospitals for non-emergency |be coordinated by your PCP.|BCBS for assistance in |with BCBS to provide reduced or |
| |a primary physician to direct |care and certain doctors, including specialist for certain |The PCP must refer you to |locating a provider or visit|discounted fees. |
| |and coordinate your health |services. |other providers and | | |
| |care needs. |• You do not need a referral when you have a medical emergency. |specialists who are in the |. | |
| | |You should seek treatment at the nearest medical facility. |same IPA as the PCP. Female|Participants may choose a | |
| | |• You may change your PCP at any time, the change will be |plan members may self-refer|provider out-of-network. The| |
| | |effective the first of the month following your request to |to OB/GYN in the PCP’s |doctor may be a ParPlan | |
| | |change. |group for their annual |provider contracted with | |
| | | |well-woman examinations. |BCBS to provide reduced or | |
| | | |Note: Changes in the |discounted fees. | |
| | | |selection of your PCP will | | |
| | | |be effective the first of | | |
| | | |the month after you request| | |
| | | |the change. | | |
|Transportation |N/A |N / A |$0 copayment to provide |N / A |N / A | |
| | | |30 one-way trips to | | | |
| | | |plan-approved locations | | | |
| | | |every year. | | | |
|What is the lifetime |None |None |None |None |$1,500,000 per participant. | |
|maximum benefit per | | | | |Lifetime maximum does not | |
|person? | | | | |apply to coverage or | |
| | | | | |services for AIDS or human | |
| | | | | |immunodeficiency virus | |
| | | | | |infection | |
Use the chart below to find the contribution for the coverage you elect. First, look for the category in the left-hand column that fits your situation, then select the corresponding rate for the plans of your choice. If you have family members who remain in the HMO or PPO, select the rate based on the age of the oldest family member keeping the HMO or PPO plan. Your total monthly contribution is the sum of the rate for HMO or PPO, plus the rate for Aetna, TexanPlus or Texas HealthSpring.
|Contribution chart for May 2007 |
|Family Coverage Category |Contribution |
| |Aetna |TexanPlus |Texas HealthSpring |HMO* |PPO* |
|1 Retiree Only (With Medicare ) | | | |$131.44 |$399.60 |
|2 Retiree elects an MA plan |$44.00 |$6.25 |$23.25 |– |– |
|3 Retiree + One (Both have Medicare) | | | |$256.36 |$440.72 |
|4 Both elect an MA plan |$88.00 |$12.50 |$46.50 |– |– |
|5 One elects an MA plan / one keeps city plan |$44.00 |$6.25 |$23.25 |$131.44 |$399.60 |
|6 Retiree + One (Only one has Medicare) | | | |$262.96 |$1,049.76 |
|7 One elects an MA plan / one keeps city plan (less than 65) |$44.00 |$6.25 |$23.25 |$136.22 |$458.02 |
|8 One elects an MA plan / one keeps city plan (age 65+) |$44.00 |$6.25 |$23.25 |$421.38 |$621.80 |
|9 Retiree + Family (Two have Medicare) | | | |$407.56 |$1,047.30 |
|10 Two elect an MA plan / one keeps city plan (less than 65) |$88.00 |$12.50 |$46.50 |$136.22 |$458.02 |
|11 Two elect an MA plan / two keep city plan (both are less than 65) |$88.00 |$12.50 |$46.50 |$401.98 |$1,178.10 |
|12 Two elect an MA plan / two+ keep city plan (all are less than 65) |$88.00 |$12.50 |$46.50 |$626.86 |$1,647.88 |
|13 One elects an MA plan / two keep city plan (1 is 65+, 1 is less than 65) |$44.00 |$6.25 |$23.25 |$262.96 |$1,049.76 |
|14 One elects an MA plan / two+ keep city plan (1 is 65+, 2 are less than 65) |$44.00 |$6.25 |$23.25 |$447.00 |$1,140.24 |
|15 Retiree + Family (Two with Medicare + one 65+ w/o Medicare) | | | |$407.56 |$1,047.30 |
|16 Two elect an MA plan / one keeps city plan (age 65+) |$88.00 |$12.50 |$46.50 |$421.38 |$621.80 |
|17 Two elect an MA plan / two keep city plan (1 is 65+, 1 is less than 65) |$88.00 |$12.50 |$46.50 |$884.90 |$1,305.74 |
|18 Retiree + Family (Three w/ Medicare) | | | |$407.56 |$1,047.30 |
|19 Three elect an MA plan |$132.00 |$18.75 |$69.75 |– |– |
|20 Three elect an MA plan / one keeps city plan (1 is less than 65) |$132.00 |$18.75 |$69.75 |$136.22 |$458.02 |
|21 Three elect an MA plan / two keep city plan (both are less than 65) |$132.00 |$18.75 |$69.75 |$401.98 |$1,178.10 |
|22 Three elect an MA plan / two+ keep city plan (all are less than 65) |$132.00 |$18.75 |$69.75 |$628.86 |$1,647.89 |
|23 Two elect an MA plan / one keeps city plan (age 65+) |$88.00 |$12.50 |$46.50 |$131.44 |$399.60 |
|24 Two elect an MA plan / two keep city plan (1 is 65+, 1 is less than 65) |$88.00 |$12.50 |$46.50 |$262.96 |$1,049.76 |
|25 Two elect an MA plan / two + keep city plan (1 is 65+, 2 are less than 65) |$88.00 |$12.50 |$46.50 |$447.00 |$1,140.24 |
|26 One elects an MA plan / two keep city plan (2 are 65+, 1 is less than 65) |$44.00 |$6.25 |$23.25 |$262.96 |$1,049.76 |
|27 One elects an MA plan / two+ keep city plan (2 are 65+, 1 is less than 65) |$44.00 |$6.25 |$23.25 |$407.56 |$1,407.30 |
|28 Retiree + Family (Only one has Medicare) | | | |$447.00 |$1,140.24 |
|29 One elects an MA plan / two keep city plan (both are less than 65) |$44.00 |$6.25 |$23.25 |$401.98 |$1,178.10 |
|30 One elects an MA plan / two+ keep city plan (all are less than 65) |$44.00 |$6.25 |$23.25 |$626.86 |$1,647.88 |
|31 One elects an MA plan / two keep city plan (1 is 65+, 1 is less than 65) |$44.00 |$6.25 |$23.25 |$884.90 |$1,305.74 |
|32 One elects an MA plan / two+ keep city plan (1 is 65+, 2 are less than 65) |$44.00 |$6.25 |$23.25 |$1,516.98 |$1,617.64 |
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