Memorial Hermann Health Insurance Company Employer Group Health Insurance Plan Overview Houston, Texas

Transcription

1 Health Insurance Company Employer Group Health Insurance Plan Overview Houston, Texas

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3 Health Insurance Company To address the growing concerns of healthcare quality and cost, we are proud to offer a suite of employer group health insurance plans supported by the award-winning 1, 2 Health System and underwritten by Health Insurance Company. Health Insurance Company health plans are cost-efficient and focus on delivering excellence in health benefits. Health Insurance Company plans offer: A trusted network Health System is the largest not-for-profit healthcare system in Southeast Texas and has been a trusted healthcare provider for more than 100 years. Cost-efficient health benefit plans The alliance among Health System, affiliated physicians and the companies allows for more efficient healthcare and more affordable health plans. Extensive portfolio of health benefit plans Health Insurance Company plans offer access to healthcare throughout the Greater Houston area. 1) (2012) is the winner of the 2012 John M. Eisenberg Award for Quality and Patient Safety from the Joint Commission and National Quality Forum. Retrieved June 7, 2013, from 2) (2013) Four Hospitals Again Named Among America s 50 Best Hospitals by HealthGrades, the leading independent healthcare ratings organization. Retrieved June 7, 2013, from 1

4 Ella Boulevard East Map of In-Network Hospitals Huntsville Veterans Memorial Pkwy. The Woodlands Hospital 1374 Sam Houston Ave. Huntsville Memorial Hospital Surgical Hospital Kingwood Tomball Regional Medical Center GEORGE BUSH INTERCONTINENTAL AIRPORT Northeast Hospital Sam Houston Parkway / Beltway 8 59 North Hardy Toll Road Freeway Freeway 8 Northwest Freeway / I-45 N Eastex Katy Hospital Katy Freeway / I-10 W Katy Freeway / I-10 W Rehabilitation Hospital-Katy Grand Parkway West 6 Prevention and Recovery Center 10 Heart & Vascular Institute Westheimer Rd. Gessner Heart & Vascular Institute Memorial City Medical Center 59 Southwest Freeway 290 Loop 610 West Beechnut Southwest Hospital 90A Northwest Hospital TIRR Memorial Hermann Loop 610 North 288 Fannin St. 59 Loop 610 South 10 90A 610 Loop -Texas Medical Center/ Children s Hospital Mischer Neuroscience Institute HOBBY AIRPORT East Freeway / I-10 E 225 Sugar Land Hospital 59 8 Nolan Ryan Expressway Sam Houston Parkway / Beltway 8 Southeast Hospital Astoria Beamer Rd. 45 ELLINGTON FIELD Anchor Rd. Angleton 288 E. Henderson Rd. N. Downing St. Hospital Dr. E. Mulberry St. Angleton Danbury Medical Center 35 Acute-Care Hospitals Specialty Hospitals and Centers Specialty Institutes 2

5 Provider Network Health Insurance Company employer group health insurance plans are available to groups with two or more eligible employees within the Greater Houston service area.* The Select provider network within this area 1 includes physicians, hospitals and other providers affiliated with, and also includes other select providers. serves the Houston community through 12 hospitals, its network of affiliated physicians, and many specialty programs and services. This includes Memorial Hermann-Texas Medical Center, a Level I trauma center and teaching hospital for The University of Texas Health Science Center at Houston (UTHealth) Medical School. also includes 8 suburban hospitals, 3 premier Heart & Vascular Institutes, TIRR (The Institute for Rehabilitation and Research), Rehabilitiation Hospital-Katy, Children s Hospital, Women s Hospital, 3 IRONMAN Sports Medicine Institutes, the Mischer Neuroscience Institute, 7 comprehensive Cancer Centers, 30 Imaging Centers including 9 Breast Centers, 18 surgery centers, 30 sports medicine and rehabilitation centers, 21 diagnostic laboratories, a substance abuse treatment center (PaRC), and numerous other specialty and outpatient centers. operates the Life Flight air ambulance program, as well as the city s only burn treatment center. Access to 100+ healthcare facilities Life Flight transports critically ill and injured patients Expanded Network Coverage Health Insurance Company also offers a dual network option, which adds another PPO network for employers wanting a broader network in the local service area. See your agent for details. Health Solutions, Inc. and Health Insurance Company Health Solutions, Inc., a third-party administrator, and Memorial Hermann Health Insurance Company strive to deliver excellence in health benefit plans and to offer innovative products to meet the needs of our customers. Both companies are part of the Health System. Access to 5,000+ skilled physicians and specialists *Greater Houston Service Area Eighty percent of the group s employees must reside in the seven-county service area: Harris, Montgomery, Walker, Fort Bend, Brazoria, Wharton and Galveston. WALKER Huntsville Conroe MONTGOMERY HARRIS Houston Sugar Land FORT BEND Pearland GALVESTON Galveston WHARTON El Campo BRAZORIA 2 1) The Greater Houston metropolitan area consists of the following Texas counties: Harris, Montgomery, Walker, Fort Bend, Brazoria, Wharton and Galveston. 2) (2013) Four Hospitals Again Named Among America s 50 Best Hospitals by HealthGrades, the leading independent healthcare ratings organization. Retrieved June 7, 2013, from 3

6 Ella Boulevard East Our In-Network Specialty Facilities Conroe Teas Rd. 336 N. Frazier St. The Woodlands Willowbrook GEORGE BUSH INTERCONTINENTAL AIRPORT Humble Northeast Cy-Fair 249 Sam Houston Parkway / Beltway 8 59 North Hardy Toll Road Freeway Freeway / I-45 N Eastex Northwest Freeway Katy Katy Freeway / I-10 W Gessner 290 Loop 610 North Memorial City Hedwig Village Northwest East Houston Mid County Grand Parkway West Town & Country Westheimer Rd. Southwest Freeway Loop 610 West Beechnut Southwest Katy Freeway / I-10 W Upper Kirby Texas Medical Center Fannin St. Loop 610 South 90A Loop 610 East Freeway Spencer Hwy. / I-10 E A 288 HOBBY AIRPORT Pasadena Sugar Land 59 First Colony 6 8 Pearland Nolan Ryan Expressway Sam Houston Parkway / Beltway 8 Southeast Beamer Rd. Astoria ELLINGTON FIELD 45 Clear Lake LBJ SPACE CNTR. Friendswood Webster Alvin FM Imaging Centers Breast Care Centers Sports Medicine & Rehabilitation Diagnostic Laboratories Cancer Centers Ironman Sports Medicine Institutes

7 Health Insurance Company Plans Health Insurance Company offers a suite of health insurance plans designed for employer groups with at least two eligible employees. The two categories of health insurance plans vary in deductible amounts, premiums and coverage. Select and Select Plus Plans These Health Insurance Company plans offer groups a variety of health benefit plans with a broad range of valuable benefits. They are competitively priced to provide members with the protection they need, at a cost they can afford. Select HSA-Compatible Plans These Health Insurance Company plans offer groups a variety of consumer-driven health benefits. An HSA is a health savings account established exclusively for members to use to pay for current and future qualified medical expenses. In order to qualify for an HSA, a member must be enrolled in a high-deductible health plan (HDHP). Health Insurance Company s HDHPs are HSA-compatible, designed to meet certain requirements in terms of annual deductibles and annual out-of-pocket expense maximums. The HDHPs are provided by Health Insurance Company. You will select a bank or financial institution to administer your HSA. 5

8 Health Insurance Company Select Plus Health Insurance Plans (Form number MHGCCOV(08/12)) Health Insurance Company s payment for covered expenses after deductible, per member, per year unless otherwise noted. Premium will vary depending on the Plan selected. Your Insurance Plan Features Deductible Copays do not apply toward satisfying any deductible Annual Out-of-Pocket Maximum Does not include deductible select plus 500 select plus 1000 IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Member: $500 Family: $1000 Member: $2,000 Family: $4,000 Member: $1,500 Member: $10,000 Family: $20,000 Member: $1,000 Family: $2,000 Member: $2,000 Family: $4,000 Member: $3,000 Member: $10,000 Family: $20,000 Office Visits $35 copay; deductible waived $35 copay; deductible waived Preventive Care A & B Care Services** Office visits and examinations associated with the Preventive A & B care services** Immunizations for children, adolescents and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration. Routine Care Services Preventive physical exams, some lab, X-rays and immunizations other than indicated above under Preventive A & B Care Services** Professional Services Including surgery, anesthesia, radiation therapy and in-hospital doctor visits Diagnostic Lab Work and X-rays Mental, Emotional or Functional Nervous Disorders a. Inpatient hospital charges other than serious mental illness 2 b. Inpatient or outpatient professional charges Emergency Room Services 1 Urgent Care Services $35 copay; deductible waived $35 copay; deductible waived Inpatient Hospital Services 2, 3 Inpatient Medical Emergency 2, 3 until transferable thereafter, until transferable thereafter, Outpatient Medical Care 1, 3 Physical/Occupational Therapy, Maximum of 20 visits; in- and out-of-network providers combined Ambulance Service Maternity (employee and spouse only) Prescription Drug Deductible (brand-name only) N/A N/A Prescription Drugs 4 Retail Pharmacy; per prescription (up to a 30-day supply) Generic Drugs $15 copay 50% avg. wholesale price $15 copay 50% avg. wholesale price Brand-Name Formulary Drugs $30 copay 50% avg. wholesale price $30 copay 50% avg. wholesale price Brand-Name Nonformulary Drugs $45 copay 50% avg. wholesale price $45 copay 50% avg. wholesale price Self-Injectables Member pays 20% 50% avg. wholesale price Member pays 20% 50% avg. wholesale price (a) subject to the plan year in-network deductible (b) subject to the plan year out-of-network deductible ** A & B Care Services are rated by the United States Preventive Task Force 1) Emergency room visits that do not result in inpatient admissions will be subject to a $60 penalty. 2) Inpatient medical care requires pre-service review or authorization or you will be subject to a 50% reduction in benefits. This penalty is waived on emergency admissions; however, Utilization Review is still required. 3) In addition to pre-service review, certain services require authorization to be eligible for maximum benefits. This applies to: organ/tissue transplants, infusion therapy, home health services, skilled nursing facilities, hospice, and treatment of chemical dependency. Failure to obtain authorization may result in a 50% reduction in benefits. Ambulatory surgical centers must be licensed and accredited and meet all requirements of state and local laws and agencies. 4) Certain prescription drugs including but not limited to self-administered injectable drugs and injectable drugs administered in an outpatient setting, may require prior authorization. See Prescription Drug Utilization Review and Authorization Program in the Prescription Drugs section of the Certificate of Coverage for details. A current list of medications requiring prior authorization is also available at Caremark s website If you fill a prescription for a drug that requires authorization, you will receive a letter informing you of the requirement, and of how to obtain authorization for any refills. 6

9 Health Insurance Company Select Plus Health Insurance Plans Continued Health Insurance Company s payment for covered expenses after deductible, per member, per year unless otherwise noted. Premium will vary depending on the Plan selected. select plus 2000 select plus IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Member: $2,000 Family: $4,000 Member: $2,000 Family: $4,000 Member: $6,000 Member: $10,000 Family: $20,000 Member: $2,500 Family: $5,000 N/A Member: $7,500 Member: $10,000 Family: $20,000 Your Plan Features $35 copay; deductible waived $35 copay; deductible waived Office Visits Deductible Copays do not apply toward satisfying any deductible Annual Out-of-Pocket Maximum Does not include deductible Preventive Care A & B Care Services** Office visits and examinations associated with the Preventive A & B care services** Immunizations for children, adolescents and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration. Routine Care Services Preventive physical exams, some lab, X-rays and immunizations other than indicated above under Preventive A & B Care Services** Professional Services Including surgery, anesthesia, radiation therapy and in-hospital doctor visits Diagnostic Lab Work and X-rays Mental, Emotional or Functional Nervous Disorders a. Inpatient hospital charges other than serious mental illness 2 b. Inpatient or outpatient professional charges Emergency Room Services 1 $35 copay; deductible waived 50% $35 copay; deductible waived 70% Urgent Care Services Inpatient Hospital Services 2, 3 until transferable thereafter, until transferable thereafter, Inpatient Medical Emergency 2, 3 Outpatient Medical Care 1, 3 Physical/Occupational Therapy, Maximum of 20 visits; in- and out-of-network providers combined Ambulance Service Maternity (employee and spouse only) N/A N/A Prescription Drug Deductible (brand-name only) $15 copay 50% avg. wholesale price $15 copay 70% avg. wholesale price Prescription Drugs 4 Retail Pharmacy; per prescription (up to a 30-day supply) Generic Drugs $30 copay 50% avg. wholesale price $30 copay 70% avg. wholesale price Brand-Name Formulary Drugs $45 copay 50% avg. wholesale price $45 copay 70% avg. wholesale price Brand-Name Nonformulary Drugs Member pays 20% 50% avg. wholesale price Member pays 20% 50% avg. wholesale price Self-Injectables (a) subject to the plan year in-network deductible (b) subject to the plan year out-of-network deductible ** A & B Care Services are rated by the United States Preventive Task Force 1) Emergency room visits that do not result in inpatient admissions will be subject to a $60 penalty. 2) Inpatient medical care requires pre-service review or authorization or you will be subject to a 50% reduction in benefits. This penalty is waived on emergency admissions; however, Utilization Review is still required. 3) In addition to pre-service review, certain services require authorization to be eligible for maximum benefits. This applies to: organ/tissue transplants, infusion therapy, home health services, skilled nursing facilities, hospice, and treatment of chemical dependency. Failure to obtain authorization may result in a 50% reduction in benefits. Ambulatory surgical centers must be licensed and accredited and meet all requirements of state and local laws and agencies. 4) Certain prescription drugs including but not limited to self-administered injectable drugs and injectable drugs administered in an outpatient setting, may require prior authorization. See Prescription Drug Utilization Review and Authorization Program in the Prescription Drugs section of the Certificate of Coverage for details. A current list of medications requiring prior authorization is also available at Caremark s website If you fill a prescription for a drug that requires authorization, you will receive a letter informing you of the requirement, and of how to obtain authorization for any refills. 7

10 Health Insurance Company Select and Select Plus Health Insurance Plans Continued Health Insurance Company s payment for covered expenses after deductible, per member, per year unless otherwise noted. Premium will vary depending on the Plan selected. select plus 5000 select 2500 Your Insurance Plan Features Deductible Copays do not apply toward satisfying any deductible Annual Out-of-Pocket Maximum Does not include deductible Office Visits Preventive Care A & B Care Services** Office visits and examinations associated with the Preventive A & B care services** Immunizations for children, adolescents and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration. IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Member: $5,000 Family: $10,000 N/A Member: $15,000 Member: $10,000 Family: $20,000 $35 copay; deductible waived Member: $2,500 Family: $5,000 Member: $3,000 Family: $6,000 $35 copay for first 10 visits 5 Office Visits and Urgent Care Services Combined 5 Member: $7,500 Member: $10,000 Family: $20,000 Routine Care Services Preventive physical exams, some lab, X-rays and immunizations other than indicated above under Preventive A & B Care Services** Professional Services Including surgery, anesthesia, radiation therapy and in-hospital doctor visits 70% (a) Diagnostic Lab Work and X-rays 70% (a) Mental, Emotional or Functional Nervous Disorders a. Inpatient hospital charges other than serious mental illness 2 b. Inpatient or outpatient professional charges 70% (a) 70% (a) Emergency Room Services 1 70% (a) Urgent Care Services $35 copay; deductible waived $35 copay for first 10 visits Office Visits and Urgent Care Services Combined deductible waived After 10 visits 70% (a) Inpatient Hospital Services 2, 3 70% (a) Inpatient Medical Emergency 2, 3 until transferable thereafter, 70% (a) 70% (a) until transferable thereafter, Outpatient Medical Care 1, 3 70% (a) Physical/Occupational Therapy, Maximum of 20 visits; in- and out-of-network providers combined Up to $30 per visit Ambulance Service 70% (a) Maternity (employee and spouse only) 70% (a) Prescription Drug Deductible (brand-name only) N/A $100 Prescription Drugs 4 Retail Pharmacy; per prescription (up to a 30-day supply) Generic Drugs $15 copay 70% avg. wholesale price $10 copay 50% avg. wholesale price Brand-Name Formulary Drugs $30 copay 70% avg. wholesale price $25 copay 50% avg. wholesale price Brand-Name Nonformulary Drugs $45 copay 70% avg. wholesale price $50 copay 50% avg. wholesale price Self-Injectables Member pays 20% 50% avg. wholesale price Member pays 30% 50% avg. wholesale price (a) subject to the plan year in-network deductible (b) subject to the plan year out-of-network deductible ** A & B Care Services are rated by the United States Preventive Task Force 1) Emergency room visits that do not result in inpatient admissions will be subject to a $60 penalty. 2) Inpatient medical care requires pre-service review or authorization or you will be subject to a 50% reduction in benefits. This penalty is waived on emergency admissions; however, Utilization Review is still required. 3) In addition to pre-service review, certain services require authorization to be eligible for maximum benefits. This applies to: organ/tissue transplants, infusion therapy, home health services, skilled nursing facilities, hospice, and treatment of chemical dependency. Failure to obtain authorization may result in a 50% reduction in benefits. Ambulatory surgical centers must be licensed and accredited and meet all requirements of state and local laws and agencies. 4) Certain prescription drugs including but not limited to self-administered injectable drugs and injectable drugs administered in an outpatient setting, may require prior authorization. See Prescription Drug Utilization Review and Authorization Program in the Prescription Drugs section of the Certificate of Coverage for details. A current list of medications requiring prior authorization is also available at Caremark s website If you fill a prescription for a drug that requires authorization, you will receive a letter informing you of the requirement, and of how to obtain authorization for any refills. 5) Includes all office visits and urgent care services combined. After 10 visits, deductible and coinsurance apply. 8

11 Health Insurance Company Select HSA-Compatible Health Insurance Plans 5 Health Insurance Company s payment for covered expenses after deductible, per member, per year unless otherwise noted. Your Insurance Plan Features Deductible Copays do not apply toward satisfying any deductible Annual Out-of-Pocket Maximum Does not include deductible Select HSA-Compatible Plan A (with embedded deductible) Select HSA-Compatible Plan B (with aggregate deductible) IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Member: $2,600 Family: $5,200 Once annual deductible is met, co-insurance and co-pays, including pharmacy, apply. Member: $2,000 Family: $4,000 Member: $7,800 Family: $15,600 Member: $15,000 Family: $30,000 Member: $2,600 Family: $5,200 Once annual deductible is met, co-insurance and co-pays, including pharmacy, apply. Member: $2,000 Family: $4,000 Member: $7,800 Family: $15,600 Member: $15,000 Family: $30,000 Office Visits Preventive Care A & B Care Services** Office visits and examinations associated with the Preventive A & B care services** Immunizations for children, adolescents and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration. Routine Care Services Preventive physical exams, some lab, X-rays and immunizations other than indicated above under Preventive A & B Care Services** Professional Services Including surgery, anesthesia, radiation therapy and in-hospital doctor visits Diagnostic Lab Work and X-ray Mental, Emotional or Functional Nervous Disorders a. Inpatient hospital charges other than serious mental illness 2 b. Inpatient or outpatient professional charges Emergency Room Services 1 Urgent Care Services Inpatient Hospital Services 2, 3 Inpatient Medical Emergency 2, 3 until transferable thereafter, until transferable thereafter, Outpatient Medical Care 1, 3 Physical/Occupational Therapy, Maximum of 20 visits; in- and out-of-network providers combined Up to $30 per visit (a) Up to $30 per visit (a) Ambulance Service Maternity (employee and spouse only) Prescription Drug Deductible (generic and brand-name) Included in plan deductible Included in plan deductible Prescription Drugs 4 Retail Pharmacy; per prescription (up to a 30-day supply) Generic Drugs $10 copay 50% avg. wholesale price $10 copay 50% avg. wholesale price Brand-Name Formulary Drugs $25 copay 50% avg. wholesale price $25 copay 50% avg. wholesale price Brand-Name Nonformulary Drugs $50 copay 50% avg. wholesale price $50 copay 50% avg. wholesale price Self-Injectables Member pays 20% 50% avg. wholesale price Member pays 20% 50% avg. wholesale price (a) subject to the plan year in-network deductible (b) subject to the plan year out-of-network deductible ** A & B Care Services are rated by the United States Preventive Task Force 1) Emergency room visits that do not result in inpatient admissions will be subject to a $60 penalty. 2) Inpatient medical care requires pre-service review or authorization or you will be subject to a 50% reduction in benefits. This penalty is waived on emergency admissions; however, Utilization Review is still required. 3) In addition to pre-service review, certain services require authorization to be eligible for maximum benefits. This applies to: organ/tissue transplants, infusion therapy, home health services, skilled nursing facilities, hospice, and treatment of chemical dependency. Failure to obtain authorization may result in a 50% reduction in benefits. Ambulatory surgical centers must be licensed and accredited and meet all requirements of state and local laws and agencies. 4) Certain prescription drugs including but not limited to self-administered injectable drugs and injectable drugs administered in an outpatient setting, may require prior authorization. See Prescription Drug Utilization Review and Authorization Program in the Prescription Drugs section of the Certificate of Coverage for details. A current list of medications requiring prior authorization is also available at Caremark s website If you fill a prescription for a drug that requires authorization, you will receive a letter informing you of the requirement, and of how to obtain authorization for any refills. 5) See page 5 for discussion of Health Care Savings Accounts. 9

12 Health Insurance Company Select HSA-Compatible Health Insurance Plans 5 Health Insurance Company s payment for covered expenses after deductible, per member, per year unless otherwise noted. Your Insurance Plan Features Deductible Copays do not apply toward satisfying any deductible Annual Out-of-Pocket Maximum Does not include deductible Annual Pharmacy Out-of-Pocket Maximum Does not include deductible Select HSA-Compatible Plan c (with embedded deductible) Select HSA-Compatible Plan D (with aggregate deductible) IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Member: $2,600 Family: $5,200 None Member: $2,000 Family: $4,000 Member: $7,800 Family: $15,600 Member: $15,000 Family: $30,000 None Member: $2,600 Family: $5,200 None Member: $2,000 Family: $4,000 Member: $7,800 Family: $15,600 Member: $15,000 Family: $30,000 Office Visits Preventive Care A & B Care Services** Office visits and examinations associated with the Preventive A & B care services** Immunizations for children, adolescents and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration. None Routine Care Services Preventive physical exams, some lab, X-rays and immunizations other than indicated above under Preventive A & B Care Services** Professional Services Including surgery, anesthesia, radiation therapy and in-hospital doctor visits Diagnostic Lab Work and X-ray Mental, Emotional or Functional Nervous Disorders a. Inpatient hospital charges other than serious mental illness 2 b. Inpatient or outpatient professional charges Medical Emergency Room Services 1 Urgent Care Services Inpatient Hospital Services 2, 3 Inpatient Medical Emergency 2, 3 until transferable thereafter, until transferable thereafter, Outpatient Medical Care 1, 3 Physical/Occupational Therapy, Maximum of 20 visits; in- and out-of-network providers combined Up to $30 per visit (a) Up to $30 per visit (a) Ambulance Service Maternity (employee and spouse only) Prescription Drug Deductible (generic and brand-name) Included in plan deductible Included in plan deductible Prescription Drugs 4 Retail Pharmacy; per prescription (up to a 30-day supply) Generic Drugs $10 copay 50% avg. wholesale price $10 copay 50% avg. wholesale price Brand-Name Formulary Drugs $25 copay 50% avg. wholesale price $25 copay 50% avg. wholesale price Brand-Name Nonformulary Drugs $50 copay 50% avg. wholesale price $50 copay 50% avg. wholesale price Self-Injectables Member pays 20% 50% avg. wholesale price Member pays 20% 50% avg. wholesale price (a) subject to the plan year in-network deductible (b) subject to the plan year out-of-network deductible ** A & B Care Services are rated by the United States Preventive Task Force 1) Emergency room visits that do not result in inpatient admissions will be subject to a $60 penalty. 2) Inpatient medical care requires pre-service review or authorization or you will be subject to a 50% reduction in benefits. This penalty is waived on emergency admissions; however, Utilization Review is still required. 3) In addition to pre-service review, certain services require authorization to be eligible for maximum benefits. This applies to: organ/tissue transplants, infusion therapy, home health services, skilled nursing facilities, hospice, and treatment of chemical dependency. Failure to obtain authorization may result in a 50% reduction in benefits. Ambulatory surgical centers must be licensed and accredited and meet all requirements of state and local laws and agencies. 4) Certain prescription drugs including but not limited to self-administered injectable drugs and injectable drugs administered in an outpatient setting, may require prior authorization. See Prescription Drug Utilization Review and Authorization Program in the Prescription Drugs section of the Certificate of Coverage for details. A current list of medications requiring prior authorization is also available at Caremark s website If you fill a prescription for a drug that requires authorization, you will receive a letter informing you of the requirement, and of how to obtain authorization for any refills. 5) See page 5 for discussion of Health Care Savings Accounts. 10

13 Exclusions and Limitations: What the Plan Does Not Pay For Excluded Services Your Health Insurance Company Plan does not provide benefits for: A. Any amounts in excess of maximum amounts of Covered Expenses stated in this Plan. B. Services not specifically listed in this Plan as Covered Services. C. Services or supplies that are not Medically Necessary as defined by Health Insurance Company. D. Services or supplies that Health Insurance Company considers to be Experimental or Investigative. E. Services received before the Effective Date of Coverage. F. Services received after coverage ends. G. Services for which You have no legal obligation to pay or for which no charge would be made if You did not have a health plan or insurance coverage, except to the extent that the availability of insurance or health plan coverage may be considered by a tax supported institution of the State of Texas providing treatment of Mental Illness or mental retardation to determine if a patient is non-indigent, as provided in Article 3196a of Vernon s Texas Civil Statutes. H. Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers compensation, employer s liability law or occupational disease law, even if You do not claim those benefits. I. Conditions caused by or contributed to by (a) an act of war; (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an Insured Person participating in the military service of any country; (d) an Insured Person participating in an insurrection, rebellion, or riot; (e) services received for any condition caused by an Insured Person s commission of, or attempt to commit a felony; (f) an Insured Person, age 19 or older, being under the influence of alcohol, illegal narcotics or nonprescribed controlled substances unless administered on the advice of a Physician. J. Any intentionally self-inflicted Injury or Illness. K. Any services provided by a local, state or federal government agency except (a) when payment under this Plan is expressly required by federal or state law; or (b) services provided for the treatment of Mental or Nervous Disorders by a tax-supported institution of the State of Texas. L. Professional services received or supplies purchased from Yourself, a person who lives in the Insured Person s home or who is related to the Insured Person by blood, marriage or adoption, or the Insured Person s employer, unless the employer is a Hospital or Doctor of Medicine. M. Inpatient or outpatient services of a private duty nurse. N. Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, Physical Therapy or treatment of chronic pain; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service. O. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. P. Treatment of Mental, Emotional or Functional Nervous Disorders, or psychological testing except as specifically stated in this Plan. However, medical conditions that are caused by behavior of the Insured Person that may be associated with these mental conditions are not subject to these limitations but may be excluded elsewhere in this Plan. Q. Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically stated under Dental Care in the Comprehensive Benefits section of this Plan, including dental services for Temporomandibular Joint Dysfunction. R. Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction. S. Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants. T. Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Plan. U. An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia). V. Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this Plan. This includes, but is not limited to, items dispensed by a Physician. W. Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not apply to Medically Necessary Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or to medically necessary breast reconstruction performed to restore or achieve breast symmetry incident to a mastectomy, or abnormal craniofacial structure caused by congenital defects. X. Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change. Y. Treatment of sexual dysfunction, impotence and/or inadequacy. Z. Charges for pregnancy and maternity care including but not limited to normal delivery, cesarean sections, and elective abortions, except as specifically stated in the Plan under Comprehensive Benefits, pregnancy and maternity care or Complications of Pregnancy as defined in this certificate. AA. All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, except as specifically stated under Comprehensive Benefits, What the Plan Pays For Sterilization or if the In-Vitro Rider is elected. AB. Cryopreservation of sperm or eggs. AC. All non-prescription contraceptive devices and supplies including but not limited to all consultations, examinations, evaluations, medications, medical, laboratory, devices, Prescription Drugs or surgical procedures except as specifically stated in this Plan. Oral contraceptives and Prescription contraceptive devices available through a pharmacy are covered under the Prescription Drug benefit of this Policy. AD. Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment, except as provided under the Child and Adult Preventive Care Services provision. AE. Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition, including those required by employment or government authority except as specifically stated under the Professional and other Services, Child and Adult Preventive Care Services and Routine Care Services sections of this Plan. AF. Charges by a provider for telephone consultations and for Telemedicine or Telehealth Services. (Note: a Telemedicine Medical Service or Telehealth Service will not be excluded solely because the service is not provided through a face to face consultation.) 11

14 AG. Items which are furnished primarily for Your personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification including wigs, etc.). AH. Educational services except as specifically provided for Diabetes Self-Management Training or as provided or arranged by Health Insurance Company. AI. Nutritional counseling or food supplements, except for formulas necessary for the treatment of phenylketonuria and as provided under the Child and Adult Preventive Care Services provision. AJ. Durable medical equipment except as specifically stated in this Plan. Excluded durable medical equipment includes, but is not limited to: air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; and supplies for comfort, hygiene or beautification. AK. Physical and/or Occupational Therapy/Medicine, except when provided during an inpatient Hospital confinement or as specifically provided under the benefits for Physical and/or Occupational Therapy/Medicine. AL. All Infusion Therapy together with any associated supplies, Drugs or professional services are excluded except as specifically provided under the benefit for Infusion Therapy described in this Plan. AM. All Foreign Country Provider charges are excluded under this Plan except as specifically stated under Treatment received from Foreign Country Providers under the Benefits section of this Plan. AN. Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet. AO. Charges for which We are unable to determine Our liability because You or an Insured Person failed, within 60 days, or as soon as reasonably possible to (a) authorize Us to receive all the medical records and information We requested or, (b) provide Us with information We requested regarding the circumstances of the claim or other insurance coverage. AP. Charges for the services of a standby Physician. AQ. Charges for animal to human organ transplants. AR. Self-administered injectable Drugs and syringes, except as stated in the Prescription Drug Benefits section of this Plan. AS. Claims received more than 12 months after the date service was rendered. AT. Any services received on or within 12 months after the Effective Date of Coverage if they are related to a Preexisting Condition. A Preexisting Condition means a disease or condition for which medical advice, diagnosis, care, or treatment was recommended or received during the 6 months before the earlier of: (a) the effective Date of Coverage; or (b) the first day of the Waiting Period. Pregnancy is not a Preexisting Condition for the purposes of this Plan and Genetic Information is not a Preexisting Condition for the purposes of this Plan unless there has been a diagnosis of the condition related to the information. A Preexisting Condition is applicable only to the Insured Persons age 19 or older. Certain exceptions to the Preexisting Condition exclusion may be found in the Certificate of Coverage. Prescription Drug Exclusions and Limitations Generic Prescription Drug reimbursement is subject to and treated as part of any benefit maximums, limitations on Pre-existing Conditions or any other exclusions or limitations contained in this entire Plan. In addition, reimbursement will not be provided for: Drugs and medications not requiring a Prescription, except insulin Non-medical substances or items, with the exception that pharmaceuticals to aid smoking cessation are covered Drugs and medications used to induce non-spontaneous abortions Dietary supplements, cosmetics, health or beauty aids Any vitamin, mineral, herb, or botanical product which is thought to have health benefits, but does not have a Food and Drug Administration (FDA) approved indication to treat, diagnose or cure a medical condition, even if it is thought to have health benefits Drugs taken while You are in a Hospital, Skilled Nursing Facility, rest home, sanitarium, convalescent Hospital or similar facility Any Drug labeled Caution, limited by federal law to investigational use or Non-FDA approved Investigational Drugs. Any drug or medication prescribed for experimental indications (such as progesterone suppositories) Syringes and/or needles, except those dispensed for use with insulin or selfadministered injectable drugs Durable medical equipment, devices, appliances and supplies except as specifically stated under the Professional and Other Services section of this Plan Immunizing agents, biological sera, blood, blood products or blood plasma Oxygen Professional charges in connection with administering, injecting or dispensing of Drugs Drugs and medications dispensed or administered in an outpatient setting, including but not limited to outpatient Hospital facilities and doctor s offices. Such drugs and medications are covered under the Professional and Other Services benefit. Drugs used for cosmetic purposes Drugs used for the primary purpose of treating Infertility or promoting fertility, except in association with an approved Course of Treatment for In vitro Fertilization. Anorexiants or drugs associated with weight loss, except as provided under Child and Adult Preventive Care Services Drugs obtained outside the United States Allergy desensitization products, allergy serum All Infusion Therapy is excluded under this Plan except as specifically stated in the Covered Services section Drugs for treatment of a condition, Illness, or Injury for which benefits are excluded or limited by a Preexisting Condition, or other contract limitation. Growth Hormone Treatment Prescription Drugs with a non-prescription (over the counter) chemical and dose equivalent, except insulin Replacement of lost or stolen Prescription Drugs Select classes of Drugs where non-preferred medications, which have therapeutic, alternatives, have shown no benefit regarding efficacy or side effects over Preferred Drugs. However, this will not apply if the Prescriber denotes, dispense as written or do not substitute. 12

15 Notes:

16 /13 Insurance coverage is underwritten by Health Insurance Company. Health Insurance Company and the Health Insurance Company logo are registered trademarks of Health System. Copyright (c) 2013 Health System. All rights reserved.