|
Posted: July
1, 2007 |
Download Summary of Benefits  |
| Benefit Description |
Member’s Copayment FY 2008 |
| Physicians and Lab Services |
Physician Office Visit (PCP)
Specialist Office Visit |
$30 Primary Care Physician
$40 |
| Routine physicals – One per plan year for adults; periodic for children, or as directed by the primary care physician |
$30 or $40 |
| Diagnostic x-rays, mammography, and lab tests |
No copayment |
| Immunizations – For Children 0 to 6 years of age |
No copayment |
| Immunizations – For children 7 years and older, and adults |
$30 |
| Well woman exam – One per plan year |
$30 or $40 |
| Vision, speech, and hearing screenings – For all enrolled participants |
$40 |
| Speech and hearing testing – Covered for all participants |
$40 |
| Speech therapy and rehabilitative therapy, including physical and occupational therapy – Covered as any other illness and not
subject to any maximum |
$40 |
| Allergy testing |
$40 |
| Allergy serum |
50% |
| Allergy serum administration – When allergy shot is administered without an office visit |
No copayment |
| Routine eye exam – One per plan year |
$40 |
| Office surgery and procedures (all office surgeries, excluding vasectomies and tubal ligations) |
$30 or $40 |
| Maternity care – Physician services, including diagnosis of pregnancy, pre- & post-natal care and delivery
(including delivery by C-section) – see "Hospital Services" for Inpatient charges
|
No copayment |
| Family planning |
$40 |
| Vasectomy and tubal ligation |
No copayment |
| Infertility benefits |
50% |
| |
| Hospital Services |
| Inpatient hospital – Semi-private room and board or intensive care units |
$100 per day copayment per admission, 5 day max.
$1,500 max. per person per year |
| Outpatient day surgery |
$100 |
| Other inpatient charges, including medically necessary surgical procedures. Includes orthognathic surgery. Guest trays, cots, telephone, maternity kits, paternity kits and other personal items not covered |
No copayment |
| Blood and blood products – Inpatient and outpatient |
No copayment |
| Private Duty Nursing, based on medical necessity |
No copayment |
| Outpatient facilities, including pre-admission testing and/or treatment room |
No copayment |
| Emergency care – In-area and out-of-area covered at listed copayment. If hospitalized, copayment is waived |
$100 |
| Urgent care – Includes physician's after-hours care or at an urgent care facility |
$50 |
| |
| Extended Care Services – Based on Medical Necessity |
| Skilled Nursing facility – Covered up to 60 days per plan year |
No copayment |
| Hospice Care – Inpatient and outpatient |
No copayment |
| Home health |
No copayment |
| Private duty nursing |
No copayment |
| |
| Other Medical Services |
| Hearing aids – $500.00 per ear every 3 years (repairs not covered) |
Plan pays $500 per ear every 3 years |
| Hearing aid batteries – Not subject to any maximum amounts |
No copayment |
| Dental – Restoration &
correction of damage caused by external violent
accidental injury to healthy, natural teeth, occurring
while covered under the plan for services provided
within 24 months of the date of the accident. Certain
oral surgeries are covered |
$40 |
| Durable Medical
Equipment – Includes medically necessary purchase
and/or rental. Benefits for rental are limited to,
will not exceed, the purchase price of the equipment.
(Repairs are covered if not due to neglect or abuse.)
This benefit
also includes diabetic supplies as specified in
Art. 21.53G, Tex. Ins. Code |
20% |
| Prostheses – Artificial devices,
surgical or non-surgical, which replace body parts,
including arms, legs, eyes and cochlear implants
are covered. Replacements and repairs are covered
up to a $10,000 maximum per occurrence |
20% |
| Organ Transplants
– Covered as any other illness for kidney,
cornea, liver, heart, heart-lung, lung, pancreatic-kidney,
bone marrow, and other organ transplants that the
HMO determines to be not experimental and/or not
investigational
according to current medical policy guidelines.
Donor expenses are covered. Artificial organs (e.g.
heart) not covered |
No copayment
(Hospital copayments
will apply) |
| Ambulance – professional local
ground or air ambulance transportation services
to the nearest hospital, appropriately equipped
and staffed for the treatment of the participant’s
condition |
No copayment |
| |
| Behavioral
Health |
| Inpatient mental health – Covered
in full up to 30 days per plan year |
$100/day copayment per
admission,
5 day max. $1500 max./person/year |
| Inpatient serious
mental illness – Covered as any other illness |
$100/day
copayment per admission,
5 day max. $1500 max./person/year |
| Inpatient chemical dependency –
Covered as any other illness, based on medical necessity |
$100/day copayment per
admission,
5 day max. $1500 max./person/year |
| Outpatient mental
health – 25 visits per plan year |
$40 |
| Outpatient serious mental illness
– Covered as any other illness |
$40 |
| Outpatient chemical
dependency – Same as any other illness and
not subject to any maximums |
$40 |
| |
| Prescription
Drugs, Plan Year Deductible |
$50 |
| If a Brand Name medication
is dispensed when a Generic is available, member
will be responsible for the Generic Copayment plus
the cost difference between the Generic and the
Brand Name medication |
| |
| Participating Retail
Pharmacy |
*Tier
1 |
**Tier
2 |
***Tier 3 |
| Up to a 30-day supply per prescription
or refill of Non-Maintenance
medication |
$10 |
$25 |
$40 |
| Up to a 30-day
supply per prescription or refill of Maintenance
medication |
$15 |
$35 |
$55 |
| Infertility drugs are paid at 50%
copayment |
50% |
50% |
50% |
| Up to a 30-day
supply of insulin for one copayment |
$10 |
$25 |
$40 |
| Up to a 30-day
supply of each diabetic oral agent for one copayment |
$10 |
$25 |
$40 |
| The supply of necessary disposable
syringes for the insulin supply for one copayment |
$25 |
$25 |
$25 |
| This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s) and syringes as specified in Section
1358.051(2), Tex. Ins. Code. Up to a 30-day supply for a 20% copayment |
20% |
20% |
20% |
| |
| Mail
Order Pharmacy |
*Tier
1 |
**Tier
2 |
***Tier
3 |
| Up to a 90-day supply per prescription
or refill for one mail order copayment |
$30 |
$75 |
$120 |
| Oral contraceptives
up to a 90-day supply for one mail order copayment |
$30 |
$75 |
$120 |
| Infertility drugs are paid at 50%
copayment |
50% |
50% |
50% |
| Up to a 90-day
supply of insulin for one mail order copayment |
$30 |
$75 |
$120 |
| Up to a 90-day
supply of each diabetic oral agent for one mail order copayment |
$30 |
$75 |
$120 |
| The supply of necessary disposable
syringes for the insulin supply for one mail order
copayment |
$75 |
$75 |
$75 |
| This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s) and syringes as specified in Section
1358.051(2), Tex. Ins. Code. Up to a 90-day supply for a 20% copayment |
20% |
20% |
20% |
| |
 |
| *Tier 1 |
- Primarily generic drugs |
| **Tier 2 |
- Mostly preferred brand name drugs |
| ***Tier 3 |
- Non-preferred brand name drugs and other
preferred brand name drugs |
|
Community First’s
Pharmacy Benefit Manager is MedImpact. The mail-order
service is through Express Scripts. Express Scripts
can be reached at 1-800-305-1834 or on the link
on the Community First pages through the ERS web
site, www.ers.state.tx.us.
You must select a primary care physician (PCP) from
the Community First provider directory, available
through the ERS Web site. It is important to know
that if you choose a PCP from the University Physicians
Group (UPG), you may use only specialists, ancillary
providers, and facilites within the UPG network,
with the exception of behavioral health providers.
The dedicated member services lines for participants
are (210) 358-6262 or toll-free, (877) 698-7032.
Member services hours are Monday to Friday, 8:30
a.m. to 5:00 p.m. After hours, phone calls are routed
to Community First’s nurse advice line. Our offices are located at 4801 NW
Loop 410, Suite 1000, San Antonio, Texas 78229.
For more information, visit Community First through
the ERS web site at www.ers.state.tx.us.
|
