Medicare AdvantageEnrollment Guide

City of Houston

May2009

City of Houston Medicare Advantage Plan ComparisonCoverage

Medicare Advantage PlansHMO Plan

Preferred Provider Organization

Aetna TexanPlus Texas HealthSpring In-Network Out-of-Network

Who is eligible?

For a list of eligible dependents see enrollment guide.

•Retireesandeligibledependentswhoarecurrentlycoveredbyacity-sponsoredmedicalplan,enrolledinMedicarePartAandPartB,andliveintheservicearea.•Personswhohaveend-stagerenaldiseasemaynotjoinTexanPlusandTexasHealthSpring.Ifapersonjoinseitherplanandlaterdevelopsend-stagerenaldisease,themembermayremainamemberofTexanPlusorTexasHealthSpring.

•Personswhohaveend-stagerenaldiseasemayjointheAetnaPFFS.

Retireesandeligibledependentswhoarecurrentlyenrolledinacity-sponsoredmedicalplan,enrolledinMedicarePartAandPartB,andliveinHMOBlueTexasorBlueCrossBlueShieldServiceArea.

What is the service area? TheAetnaPFFSisinall50states. Brazoria,Chambers,FortBend,Galvestonzipcodes:77510,77511,77517,77518,77539,77546,77549,77563,77565,77568,77573,77574,77590,77591,77592,Harris,Hardin,Jefferson,Liberty,Montgomery,Orange,Austin,Dallas,Rockwall,Tarrant,Waller

Angelina,Brazoria,Cameron,Chambers,FortBend,Galvestonzipcodes:77510,77511,77517,77518,77539,77546,77549,77563,77565,77568,77573,77574,77590,77591,77592,Harris,Hardin,Hidalgo,Jasper,Jefferson,Liberty,Montgomery,Nacogdoches,Newton,Orange,Polk,Sabine.SanAugustine,SanJacinto,Shelby,Tyler,Walker,Waller,Willacy

Plancoversallbut34countiesinTexas.SeetheHMOdirectoryforalistofcountiesintheservicearea,orvisittheWebsiteatwww.bcbstx.com.

All50statesareintheservicearea.Areducedbenefitandhigherdeductiblesapplyforservicesobtainedout-of-network.Toidentifypartici-patingprovidersoutsideofTexas,call1-800-810-2583oruseyourzipcodetofindaprovideratwww.bcbstx.com.

Does the plan coverparticipants out of the service area?

Yes.AmemberiscoveredforinpatientandoutpatientemergencymedicalservicesinsideandoutsidetheAetnaServiceAreaandworldwide.

Yes,butonlyintheeventofamedicalemergency.TexanPlusmustbenotifiedassoonaspossible.

Yes,butonlyintheeventofamedicalemergency.TexasHealthSpringmustbenotifiedassoonaspossible.

Yes,intheeventofamedicalemergencynotifyHMOBlueTexaswithin48hoursofinitialtreatment.Seekserviceswithin12hoursaftertheonsetofanillnessorwithin48hoursafteranaccident.

Yes,participantsarecoveredathomeoraway,24-hoursaday,usingtheirchoiceofphysicians.Areducedbenefitandhigherdeductiblesapplyforservicesobtainedout-of-network.ThereisemergencycarecoverageoutsideoftheContinentalUnitedStates.ToidentifyparticipatingprovidersoutsideofTexas,call1-800-810-2583.

What are the annual deductibles? None. None. None. None. Individual:$200Family:$600

Individual:$400Family:$1,200

Office Visits •$15foreachprimarydoctorofficevisitsforMedicare-coveredservices.•$15foreachspecialistvisitforMedicare-coveredservices.

•$10foreachPCPofficevisitforMedicare-coveredservices.•$25foreachspecialistvisitforMedicare-coveredservices.

•$10foreachPCPofficevisitforMedicare-coveredservices.•$25foreachspecialistofficevisitforMedicare-coveredservices.

$20copaymentforprimarycarephysician.$45copaymentforspecialist.

$30copaymentforprimarycarephysician.$50copaymentforspecialist.

40%afterannualdeductible.

Routine Physicals / Checkups $0forPreventiveCarethatincludesroutinephysical,bonemassmeasure-ment,colorectalscreeningexams,prostatescreeningexam,pelvicexam,mammography,papsmear,andFlu,pneumoniaandhepatitisvaccines.

•$10foreachPCPofficevisitandoneroutinephysicalexamannuallyforMedicare-coveredservices.

•$25foreachspecialistvisitforMedicare-coveredservices.•$0foraone-timephysicalexamwithinthefirst6monthsthatyouhaveMedicarePartB,ifyourcoveragebeganonorafter1/1/07.

•$0for1annualroutinephysical.•$10foreachPCPofficevisitandoneroutinephysicalexamannuallyforMedicare-coveredservices.

•$25foreachspecialistofficevisitforMedicare-coveredservices.

$0copayment.Onewellwomanandonewellmanexamper12months.

$0copayment.Onewellwomanandonewellmanexamper12months.

40%afterannualdeductible.

Hospital Emergency Room Charges per visit $50foreachoutpatientemergencyroomvisit.

Thecopaymentiswaivedifthepatientisadmittedtothehospital.

•$50foreachMedicare-coveredemergencyroomvisit;waivedifadmit-tedwithin48hoursforthesamecondition.

•NOTcoveredoutsidetheU.S.exceptunderlimitedcircumstances.

•$50forMedicare-coveredemergencyroomvisit;waivedifadmittedwithin3daysforthesamecondition.

•World-wideemergencycare.Ifyougetinpatientcareatanon-planhospitalafteryouremergencyconditionisstabilized,yourcostisthecostsharingyouwouldpayataplanhospitalwithplanauthorization.

$150pervisit(waivedifadmittedtothehospital).YoumustnotifyyourPCPorBCBSwithin48hours.Physician’sofficeafterhours:$20pervisit.

$150copaymentplus20%foremergencywithin48hoursofaccident/medicalemergency.Illnessanytime.Copaymentwaivedifadmittedtohospital.

$150copaymentplus40%afterdeductibleforemergencyafter48hoursoftheaccident/medicalemergency.Copaymentwaivedifadmit-tedtohospital.

Urgent Care for Minor Emergencies $15foreachurgentlyneededcarevisit. •$50foreachMedicare-coveredurgentlyneededcarevisit.•Copaymentwaivedifadmittedwithin24hoursforthesamecondition.•Coverageavailableatanyurgentcarefacility.NOTcoveredoutsidetheU.S.exceptunderlimitedcircumstances.

•$40foreachMedicare-coveredurgentlyneededcarevisit.•Copaymentwaivedifadmittedwithin3day(s)forthesamecondition.•World-widecoverage.

Office Visits:$20copayment.Urgent Care Center:$40copayment.

Office Visits:$30copayment.Urgent Care Center:$60copayment.St.Luke’sCommunityEmergencyCenterrequires$150EmergencyRoomcopayment.

Office Visits:40%afterannualdeductible.Urgent Care Center: 40%afterannualdeductible.

Ambulance Service $15foreachMedicare-coveredone-waytrip. $50foreachMedicare-coveredambulanceone-wayservice. $100foreachMedicare-coveredone-wayambulanceservice;youdonotpaythisamountifyouareadmittedtothehospital.

$100Copayment Eligibleexpensesat20%afterannualdeductible. Eligibleexpensesat40%afterannualdeductibleismet.

Inpatient HospitalAdmissions

$0peradmission. $300foreachMedicare-coveredstayinanetworkhospital.Nocopay-mentforadditionaldays.Coveredforunlimiteddayseachbenefitperiod.

•$275foreachMedicare-coveredstayinanetworkhospital.Nocopay-mentforadditionaldays.Coveredforunlimiteddayseachbenefitperiod.

•Ifyouarereadmittedtothehospitalwithin3daysforthesamediag-nosisyourcopaymentwillbewaived.

$500copaymentperhospitaladmission.Pre-authorizationrequired. 20%after$500copaymentperadmission.Pre-authorizationrequired. 40%after$1,000copaymentperadmission.Pre-authorizationre-quired.

$250copaymentforfailuretogetpre-authorization.Outpatient Surgery $0foreachMedicare-coveredprocedure. $125foreachMedicare-coveredvisitorprocedureinanambulatory

surgicalfacility.$175foreachMedicare-coveredprocedureinanoutpatienthospitalfacility.

$200foreachMedicare-coveredvisittoorprocedureinanambula-torysurgicalcenteroroutpatienthospitalfacility.

$200copaymentforeachprocedure.Pre-authorizationisrequired. 20%afterannualdeductibleforeachprocedure. 40%afterannualdeductibleforeachprocedure.

Long-term acute care (LTAC) NotCovered. •$300perLTACadmissionforthefirst60daysoftheLTACadmission.(waivedifLTACadmissionisatransferfromaninpatientacutecareset-ting).

•$228perdayfordays61-90perbenefitperiod.•$456pereachlifetimereserveday(maximum60lifetimereservedays).

•$0for1-15days•$50for16+days

N/A N/A N/A

Home Health ThereisnocopaymentforMedicare-coveredhomehealthvisits. ThereisnocopaymentforMedicare-coveredhomehealthvisits. ThereisnocopaymentforMedicare-coveredhomehealthvisits. $20copaymentforeachvisit.Pre-authorizationrequired. Skilled,non-custodialhomehealthcareservicesare20%afterannualde-ductible.Limitedto60visitspercalendaryear.Pre-authorizationrequired.

Skilled,non-custodialhomehealthcareservicesare40%afterannualde-ductible.Limitedto60visitspercalendaryear.Pre-authorizationrequired.

Hospice CoveredbyMedicareinaMedicare-certifiedhospice. $0copaymentinaMedicare-certifiedhospicefacility. $0copaymentinaMedicare-certifiedhospicefacility. $0copayment.Pre-authorizationrequired.Maximumcalendaryearbenefitis$20,000.

Inpatient:Eligibleexpensessubjectto$500hospitalinpatientcopay-mentand20%.Outpatient: Eligibleexpenses,$30copaymentpervisit.

Servicesotherthanthoseprovidedbyhospicefacility,suchasattend-ingphysician’sservices,aresubjectto20%aftertheplandeductible.

Inpatient:Eligibleexpensessubjectto$1,000hospitalinpatientcopaymentand40%.Outpatient:Eligibleexpenses,40%afterdeductible.

Servicesotherthanthoseprovidedbyhospicefacility,suchasattendingphysician’sservices,aresubjectto40%afterplandeductible.

Note:IfthereexistsaconflictbetweenthisMedicalPlansComparisonandtheofficialplandocumentsforeachplan,theofficialplansdocumentswillprevail.Inallmattersofcoverage,onlyeligibleexpenseswillbecoveredandpaidaccordingtoplansprovision.Ifpre-authorizationsarerequiredformedicalservices,penaltieswillapplyifthoseservicesarereceivedwithoutauthorization.TheCityofHoustonreservestherighttochangeormodifybenefitsprovidedundertheseplanswithoutconsent,authorizationorpriornoticetocoveredmembers.Aetna,SelectCareofTexas(TexanPlus),andTexasHealthSpringprovideadditionalbenefits.Foracompletelistingofallbenefitsandservices,pleaserefertotheEvidenceofCoveragefortheplanthatyouselect.

Medicare AdvantageComparison Chart

Making SMART health choices

Contribution Rates

Contribution chart for May 2009

Family Coverage Category Monthly Retiree Contributions

AetnaTexanPlus

Texas Health-SpringHMO*PPO*

Retiree Only (Has Medicare)$166.18$506.60

1 Retiree elects an MA plan$61$9.76 $18 ––

Retiree + One (Both have Medicare)$324.12$713.14

2 Both elect the same MA plan$122$19.52 $36 ––3 Each elects a seperate plan$61$9.76$18 $166.18$506.60Retiree + One (Only one has Medicare)$332.46$1,089.784 One elects an MA plan / one keeps city plan (less than 65)$61$9.76$18 $185.36$580.405 One elects an MA plan / one keeps city plan (age 65+)$61$9.76$18 $503.62$816.36Retiree + Family (Two have Medicare)$515.28$1,326.026 Two elect the same MA plan / one keeps city plan (less than 65)$122$19.52$36 $185.36$580.407 Two elect the same MA plan / two keep city plan (both are less than 65)$122$19.52$36 $546.98$1,499.428 Two elect the same MA plan / two+ keep city plan (all are less than 65)$122$19.52$36 $853.00$2,105.549 One elects an MA plan / two keep city plan (1 is 65+, 1 is less than 65)$61$9.76$18 $332.46$1,089.7810 One elects an MA plan / two+ keep city plan (1 is 65+, 2 are less than 65)$61$9.76$18 $565.14$1,451.32Retiree + Family (Two with Medicare + one 65+ w/o Medicare)$515.28$1,326.0211 Two elect the same MA plan / one keeps city plan (age 65+)$122$19.52$36 $503.62$816.3612 Two elect the same MA plan / two keep city plan (1 is 65+, 1 is less than 65)$122$19.52$36 $1,057.62$1,731.38Retiree + Family (Three w/ Medicare)$515.28$1,326.0213 Three elect an MA plan $183$29.28 $54 ––14 Three elect the same MA plan / one keeps city plan (1 is less than 65)$183$29.28 $54 $185.36$580.4015 Three elect the same MA plan / two keep city plan (both are less than 65)$183$29.28 $54 $546.98$1,499.4216 Three elect the same MA plan / two+ keep city plan (all are less than 65)$183$29.28 $54 $853.00$2,105.54 17 Two elect the same MA plan / one keeps city plan (age 65+)$122$19.52 $36 $166.18$506.6018 Two elect the same MA plan / two keep city plan (1 is 65+, 1 is less than 65)$122$19.52$36 $332.46$1,089.7819 Two elect the same MA plan / two + keep city plan (1 is 65+, 2 are less than 65)$122$19.52 $36 $565.14$1,451.3220 One elects an MA plan / two keep city plan (2 are 65+)$61$9.76$18 $324.12$713.1421 One elects an MA plan / two+ keep city plan (2 are 65+, 1 is less than 65)$61$9.76$18 $515.28$1,326.02Retiree + Family (Only one has Medicare)$565.14$1,451.3222 One elects an MA plan / two keep city plan (both are less than 65)$61$9.76$18 $546.98$1,499.4223 One elects an MA plan / two+ keep city plan (all are less than 65)$61$9.76$18 $853.00$2,105.5424 One elects an MA plan / two keep city plan (1 is 65+, 1 is less than 65)$61$9.76$18 $1,057.62$1,731.3825 One elects an MA plan / two+ keep city plan (1 is 65+, 2 are less than 65)$61$9.76$18 $1,813.04$2,154.98

* Rates displayed for the HMO and PPO are for participants who do not use tobacco products. If the participant or a family member uses tobacco products, the rate is $25 higher per month. This additional amount does not apply to TexanPlus, Texas HealthSpring, or Aetna PFFS.

Usethechartbelowtofindthecontributionforthecoverageyouelect.First,lookforthecategoryintheleft-handcolumnthatfitsyoursituation,thenselectthecorrespondingratefortheplansofyourchoice.IfyouhavefamilymemberswhoremainintheHMOorPPO,selecttheratebasedontheageoftheoldestfamilymemberkeepingtheHMOorPPOplan.YourtotalmonthlycontributionisthesumoftherateforHMOorPPO,plustherateforAetna,TexanPlusorTexasHealthSpring.

Va

lue

Ad

de

d S

erv

ice

s

AetnaEyeMed Vision Services•Discountvisionservicesandeyecare•Reducedfeesforeyeglassframesandlens•15percentoffcontactlens•15percentoffLasikProcedure

Alternative Health Care ProgramsAccessspecialratesonalternativetherapies,products,andservices,including:1.Naturalalternatives•Acupuncture•Massage•Chiropracticservices(Considerusingplan benefitsfirst.)

2.VitaminAdvantagePaydiscountsfor:•Over-the-countervitamins•Nutritionalsupplements

3.NaturalCareProducts

TexanPlusHearPO Hearing Discount Services:•30%discountonhearingexamsandservices.•Upto62%savingsonhearingaidsataparticipatingprovider.•Discountsonrepairsandbatteries.•Accesstonewestdigitaltechnology.•Locateahearingproviderat1-800-456-6801Hearing Aid:•TexanPluswillpayaone-time$500cashpaymentpercoveredmemberforthepurchaseofahearingaid.•Youmayuseanyhearingaidprovider;however,youcanreceiveuptoa62percentdiscountifyougotoHearPO.Toreceiveyourreimburse-ment,submitacopyofthereceiptforyourhearingaidtoTexanPlus,andtheywillsendachecktoyouforupto$500.

EyeMed Vision Services:•Discountedvisionservicesandeyecare.•Thisincludesa$25copaymentforanannualeyeexamanddiscountsonframesandlenses.•Lookinyourproviderdirectoryforalistofnetworkeyedoctors.Careington Dental Discount Services:•Receive20%-50%offmostdentalprocedures.•Upto20%discountonspecialtyservices.•Cosmeticdentistryandteethwhiteningincluded.•24,000participatingproviders.•Locateadentalproviderat1-800-290-0523ElderCare Services - NurseNavigator:•Workswithyoutoidentifyelder-careneeds.•Evaluateoptions,putsolutionsinplace.•Provideon-goingsupportneededtomaintainindependenceandqualityoflife.•Wellnessassessments,careplanningtools.•24-hourNurseNavigatorelder-careadvisor.•Significantdiscountsonseniorhousingalternatives&additionalcareservices.

Texas HealthSpringFitness Benefit:MembersmayenrollinSilverSneakersFitnessprogramthatallowsthemaccesstohealthclubsandparticipateinclassesspecificallydesignedforSeniors.•Uponenrollmentthememberwillbeprovidedwithnumerousfitnessandhealthcentersinthelocalarea.•Fulluseofamenitiesincludingfreeweights,treadmills,aerobicclasses,aswellasfitnessprogramsspecificallytailoredfortheneedsofseniors.

•Acustomerservicedepartmentreadytoansweranyquestionsregardingtheprogramandtoassistwithenrollment.Careington Dental Discount Services:•Receive20%-50%offmostdentalprocedures.•Upto20%discountonspecialtyservices.•Cosmeticdentistryandteethwhiteningincluded.•24,000participatingproviders.•Locateadentalproviderat1-800-290-0523.Free Rides:•Freeridesareprovidedtoplan-approvedhealthfacilities,suchasdoctor’sappointments,hospitals,andpharmacies.Upto30one-waytripsor15roundtripspercalendaryear.

Discount Hearing Aids:•Discounthearingservicesprovideupto30%.•Discountforhearingaidsfromselectedproviders.PAL–Personal Assistant Liaison:•PALsproactivelyengagemembersinTHS’benefitsplan.PALswill“reachout”tomembersandencouragethemtouseplanbenefits,educatethemaboutprogramsandservices,andresolvemembers’problems.

Informed Healthline•24hourinformedHealthlinestaffedwithregisterdnurses

CoverageMedicare Advantage Plans

HMO PlanPreferred Provider Organization

Aetna TexanPlus Texas HealthSpring In-Network Out-of-Network

Skilled Nursing Facility •$0perdayfordays1-10•$25perdayfordays11–20•$50perdayfordays21–100•Apriorhospitalconfinementisnotrequired.

Youarecoveredfor100dayseachbenefitperiod.

•$0/dayforday(s)1–20withimmediatepriorinpatientacutecare.•$300/dayforday(s)1–20Nopriorhospitalstayisrequired.•$100/dayforday(s)21-100

Youarecoveredfor100dayseachbenefitperiod.

•$25/dayforday(s)1-100forastayinaskillednursingfacility•Nopriorhospitalstayisrequired.

Youarecoveredfor100dayseachbenefitperiod.

$25perday.(Maximumof60dayspercalendaryear.) Eligiblefacilityexpensessubjectto$500hospitalinpatientcopayment:20%thereafter.Copaymentwaivedfortransferfrominpatienthospitallevelofcaretoaskillednursinglevelofcare.

Servicesotherthanthoseprovidedbyskillednursingfacility,suchasattendingphysician’sservices,aresubjectto20%coinsuranceafterthedeductible.

Eligiblefacilityexpensessubjectto$1,000hospitalinpatientcopayment;40%thereafter.Copaymentwaivedfortransferfrominpatienthospitallevelofcaretoaskillednursinglevelofcare.

Servicesotherthanthoseprovidedbyskillednursingfacility,suchasattendingphysician’sservices,aresubjectto40%coinsuranceafterthedeductible.

Coverageislimitedtothefollowingconditions:Ifparticipantisnotadmittedtoaskillednursingfacilityandacutecarehospitalizationwouldbeneeded,theattendingphysicianmustorderthecareandtheadministratormustpre-authorizeit.

Coverageisalsolimitedtoamaximumof60dayspercalendaryear.Custodialcareorcareforpersistentillnessesanddisordersthat,intheadministra-tor’sopinion,cannotberelievedorimprovedbymedicaltreatmentarenotcovered.

Chiropractic Services $15foreachMedicare-coveredvisit(manualmanipulationofthespine) $25foreachMedicare-coveredvisit(manualmanipulationofthespinetocorrectsubluxation).

$25foreachMedicare-coveredvisit(manualmanipulationofthespinetocorrectsubluxation).

$45specialistcopayment.Nomaximumamount. Specialist Visit: 20%after$50copayment.Other Services:20%afterannualdeductibleinoutpatientsetting.

Office Visit:20%afterannualdeductible.Other Services:40%afterannualdeductibleinoutpatientsetting.

Combinedannuallimitis$1,000percalendaryear,includingallX-rays,lab,medicines,etc.

Inpatient Mental Health Services $0peradmission.Combinedmaximumof190daysperlifetimeforallinpatientmentalhealth.DetoxificationandrehabilitationforsubstanceabusetreatmentinaMedicare-certifiedpsychiatrichospital.(Inpatientservicesinageneralhospitalhavenomaximumdaylimit.)

$300foreachMedicare-coveredstayinanetworkhospital.Thereisa190-daylifetimelimitinapsychiatrichospital.ThebenefitdaysusedundertheOriginalMedicareprogramwillcounttowardsthe190-daylifetimereservedayswhenenrollinginTexanPlus.

$275foreachMedicare-coveredstayinanetworkhospital.Thereisa190-daylifetimelimitinapsychiatrichospital.ThebenefitdaysusedundertheOriginalMedicareprogramwillcounttowardsthe190-daylifetimereservedayswhenenrollinginTexasHealthSpring.

Ifadmissionisdeemedmedicallynecessary,100%after20%copaymentperadmission.30daysmaximumpercalendaryear.Pre-authorizationrequired.

20%after$500copaymentperadmission;30daysmaximumpercalen-daryear.Pre-authorizationrequired.

40%after$1,000copaymentperadmission;15daysmaximumpercalen-daryear.Pre-authorizationrequired.

Outpatient Mental Health Services

Note:EmergencyRoomvisitswillrequireEmergencyRoomCopayment.

$25foreachMedicare-coveredmentalhealthvisit ForMedicare-coveredmentalhealthservices,youpay$35/individualpervisitand$20/grouppertherapyvisit.

ForMedicare-coveredmentalhealthservices,youpay$25/individualpervisitand$25/grouppertherapyvisit.

Office Visit:$25copaymentpersession.Maximumof20sessionspercalendaryear.

PCP Visit:20%after$30copayment.30visitsmaximumpercalendaryear,includesoutpatientvisits.

Office Visit:40%afterannualdeductible.30visitsmaximumpercalendaryear,includesoutpatientvisits.

Chemical Dependency Services/Substance Abuse Emergency Room: $50foreachMedicare-coveredemergencyroomvisit.TheCopaymentiswaivedifthepatientisadmittedtothehospital.Office Visit: $15foreachMedicare-coveredvisitInpatient: $0peradmissionCombinedmaximumof190daysperlifetimeforallinpatientmentalhealthanddetoxificationandrehabilitationsubstanceabusetreatmentinaMedicare-certifiedpsychiatrichospital.(Inpatientservicesinageneralhospitalhavenomaximumdaylimit.)

Emergency Room:$50foreachMedicare-coveredemergencyroomvisit;waivedifadmittedwithin48hours.NOTcoveredoutsidetheU.S.exceptunderlimitedcircumstances.Office Visit:$35perindividualvisitand$20pergrouptherapyvisitforMedicare-coveredservices.Inpatient:$300foreachMedicare-coveredstayinanetworkhospital.Nocopay-mentforadditionaldays.Coveredforunlimiteddayseachbenefitperiod.

Emergency Room:$50forMedicare-coveredemergencyroomvisit;waivedifadmittedwithin3days.WorldwideEmergencyCare.Office Visit:$25foreachindividual/grouptherapyvisit.Inpatient:$275foreachMedicare-coveredstayinanetworkhospital.Coveredforunlimiteddayseachbenefitperiod.Ifreadmittedtothehospi-talwithin3daysforthesamediagnosis,copaymentwillbewaived.

Emergency Room:$150copayment.Copaymentwaivedifadmitted.Office Visit:$20copayment.Specialist Visit: $45copaymentInpatient: $500copaymentforeachadmission.Limitedto3seriesoftreatmentsperlifetimeofindividual.Pre-authorizationrequired.

Emergency Room:20%after$150copayment.Copaymentwaivedifadmitted.Primary Physician Visit:20%after$30copayment.Specialist Visit: 20%after $50copaymentInpatient: 20%after$500copaymentforeachadmission.Limitedto3seriesoftreatmentsperlifetimeofindividual.

Emergency Room: 40%after$150copaymentandafterdeductible.Copaymentwaivedifadmitted.Office Visit:40%afterannualdeductible.Inpatient:40%after$1,000copaymentforeachadmission.Limitedto3seriesoftreatmentsperlifetimeofindividual.Pre-authorizationrequired.

Physical Therapy/Outpatient Rehabilitation $15foreachMedicare-coveredvisit.Servicesincludeoutpatientphysicaltherapy,occupationaltherapy,speechandlanguagetherapy

$25foreachMedicare-coveredOccupationalTherapyvisit.

$25foreachMedicare-coveredPhysicalTherapyand/orSpeech/LanguageTherapyvisit.

$25foreachMedicare-coveredOccupationalTherapyvisit.

$25foreachMedicare-coveredPhysicalTherapyand/orSpeech/LanguageTherapyandcardiacrehabilitationvisits.

$45specialistcopaymentpervisit.Unlimitedphysicaltherapyvisitsthatcontinuetomeetorexceedtreatmentgoalssetbyphysician.Forphysicallydisabledpersons,treatmentgoalsmayincludemaintainingfunctionorpreventingorslowingfurtherdeterioration.Pre-authorizationrequired.

Specialist visit:20%after$50copayment.Outpatient:20%afterdeductibleUnlimitedphysicaltherapyvisitsthatcontinuetomeetorexceedtreat-mentgoalssetbyphysician.Forphysicallydisabledpersons,treatmentgoalsmayincludemaintainingfunctionorpreventingorslowingfurtherdeterioration.Pre-authorizationrequired.

40%afterdeductible.Unlimitedphysicaltherapyvisitsthatcontinuetomeetorexceedtreatmentgoalssetbyphysician.Forphysicallydisabledpersons,treatmentgoalsmayincludemaintainingfunctionorpreventingorslowingfurtherdeterioration.Pre-authorizationrequired.

Durable Medical Equipment 15%ofthecostforeachMedicare-covereditem 10%ofthecostforeachMedicare-covereditem. 10%ofthecostforeachMedicare-covereditem. Eligibleexpensescoveredwith20%copaymentforrentalorpurchase(initialplacementonly)ofsuchequipmentwhenpre-authorizedanddeter-minedtobemedicallynecessarybyBCBS.RentalorpurchaseisdeterminedbyBCBS.CoverageislimitedtoequipmentlistedintheHealthCareFinanceAdministrationCoveragesIssueManual.Covershearingaidbenefitof$1,000per36-monthperiod.

Eligibleexpensesare20%afterannualdeductibleforrentalorpurchase(initialplacementonly)ofsuchequipmentwhenpre-authorizedanddeter-minedtobemedicallynecessarybyBCBS.CoverageislimitedtoequipmentlistedintheHealthCareFinanceAdministrationCoveragesIssueManual.Covershearingaidbenefitof$1,000per36-monthperiod.

Eligibleexpensesare40%afterannualdeductibleforrentalorpurchase(ini-tialplacementonly)ofsuchequipmentwhenpre-authorizedanddeterminedtobemedicallynecessarybyBCBS.CoverageislimitedtoequipmentlistedintheHealthCareFinanceAdministrationCoveragesIssueManual.Covershearingaidbenefitof$1,000per36-monthperiod.

Diabetic Equipment, Self-Monitoring and Training Supplies

Diabetic self-monitoring training:$0copaymentDiabetic equipment:$0ofeligiblechargesDiabetic supplies:$0copaymentforeachcovereditemincludingInjectable insulin (31-day supply): •$10generic•$30brand

Diabetic self-monitoring training:$0copaymentDiabetic equipment: 10%ofeligiblechargesDiabetic supplies:10%ofthecostforeachcovereditemInjectable insulin (31-day supply):•$10generic•$30brand

Diabetic self-monitoring training:$0copaymentDiabetic equipment: 20%ofeligiblechargesDiabetic supplies: 20%ofthecostforeachcovereditemInjectable insulin (30-day supply):•$10generic•$30brand

Diabetic equipment:20%ofeligiblechargesDiabetic supplies:sameasprescriptiondrugcoverageDiabetes Self-Management Training Programs:$0copaymentInjectable insulin (30-day supply): Seeprescriptiondrugbenefit.

Eligibleexpensesat20%after$30copayment.Diabeticequipment,self-managementtrainingandsuppliesarecoveredonthesamebasisasbenefitsareprovidedfortreatmentofothersimilarchron-icmedicalconditions.Alsocovered:disposableorconsumableoutpatientdiabeticsupplies,equipmentandsuppliesthatdonotrequireaprescriptionunderstatelaw,andinjectableinsulin.Injectable Insulin (30-day supply): Seeprescriptiondrugbenefit.

Eligibleexpensesat40%afterdeductibleismet.Diabeticequipment,self-managementtrainingandsuppliesarecoveredonthesamebasisasbenefitsareprovidedfortreatmentofotheranalogouschronicmedicalconditions.Alsocovered:disposableorconsumableoutpatientdiabeticsupplies,equip-mentandsuppliesthatdonotrequireaprescriptionunderstatelaw,andinjectableinsulin.Injectable Insulin (30-day supply): Seeprescriptiondrugbenefit.

Lab & X-rays •$15pervisitfordiagnosticlaboratory,X-Ray,andnucleartesting•$15foreachPETScan•$15foreachCATScan•$15foreachMRI•$15foreachvisitforoutpatientchemotherapy,dialysisandradiation

•$0forspecimendrawingoreachcoveredlaboratoryservice•$75foreachMRI,MRA,CTScan•$100foreachIMRT•$150foreachPETScan•$25foreachMedicare-coveredradiationtherapy•$0foreachMedicare-coveredX-rayvisitinthephysician’sofficeorfreestandingfacility

•$0forspecimendrawing,labservice•$25foreachMedicare-coveredradiationtherapy•$0foreachMedicare-coveredX-rayvisitinthephysician’sofficeorfreestandingfacility

•$150foreachPETscan•$100foreachMRI,CTorcardiacnuclearmedicinescan

$0copayment.Includedinphysician’sofficevisit. Office Visit:$30copaymentElgibleexpensescoveredat100%whenassociatedwithaphysicianofficevisit.

40%afterannualdeductible.

Bone Mass Measurement $0copayment $0copayment $20copayment-PrimaryCarePhysicianvisit$45copayment-Specialistvisit

$30copayment-PrimaryCarePhysicianvisit$50copayment-Specialistvisit

40%afterannualdeductibleismet.

Colorectal Cancer Screening (Includesfecaloccultbloodtest,aflexiblesigmoidoscopyandcolonoscopy)

$0copayment $0copaymentforage50andolder:•Flexiblesigmoidoscopy–every48months.•Fecaloccultbloodtest-every12months.•Memberwithriskfactors:Colonoscopyevery24months.•Memberwithlowriskfactors:Colonoscopyevery10years.

$0copaymentforage50andolderormemberswithriskfactors:•Fecaloccultbloodtest–everyyear•Flexiblesigmoidoscopy-every5years.•Colonoscopy–every10years.

$0copaymentforage50andolderormemberswithhighriskfactors:•Fecaloccultbloodtest–everyyear.•Flexiblesigmoidoscopy–every5years.•Colonoscopy–every10years.

40%afterannualdeductibleforage50andolderormemberswithhighriskfactors:•Fecaloccultbloodtest–everyyear.•Flexiblesigmoidoscopy–every5years.•Colonoscopy–every10years.

Routine Immunizations $0copaymentforimmunizationsforflu,pneumonia,andHepatitisB. •$0copaymentforthePneumoniaandFluvaccines.•NoreferralnecessaryforPneumoniaandFluvaccines.•$0copaymentfortheHepatitisBvaccine.

$0copaymentifserviceprovidedduringanofficevisit.Otherwisea$20copaymentapplies.

$0copaymenttoage6.Afterage6,$30copayment. $0copaymenttoage6.Afterage6,40%afterannualdeductible.

Well-Woman Exam (Includesclinicalbreastexams,mammogram,pelvicexam&papsmear)

$0copayment •$0copaymentforMedicare-coveredscreening:papsmear,breastexamorpelvicexamevery24months.•Age40andolder:Breastexamormammogramevery12months.•Memberswithhighriskcervicalcancerfactorsandareofchildbearingage:Papsmearevery12months.•NoreferralnecessaryforMedicare-coveredscreeningsperformedbyanetworkprovider.

$0copayment(Oneexamper12months).Mammogram-overage40orfamilyhistoryofbreastcancerexists.

$0copayment.(Oneexamper12months).Mammogram-overage40orfamilyhistoryofbreastcancerexists.

40%afterannualdeductible.(Oneexamper12months).Mammogram-overage40orfamilyhistoryofbreastcancerexists.

Well-Man Exam – ProstateCancerScreeningforage50andolder.(Includesprostateexamination&prostatespecificantigentest)

$0copayment $0copaymentforMedicare-coveredexamsonceevery12months. $0copaymentforMedicarecoveredexamsonceevery12months. $0copayment-oneexamper12months.(includesmembersage40withafamilyhistoryofprostatecancerorpros-tatecancerriskfactors)

$0copayment-every12months.(includesmembersage40withafamilyhistoryofprostatecancerorprostatecancerriskfactors)

40%afterannualdeductible–every12months.(includesmembersage40withafamilyhistoryofprostatecancerorprostatecancerriskfactors)

Prescriptions

Ifphysicianprescribesorallowsagenericdrug,butthepatientrequestsbrand,thecopaymentwillbethedifferencebetweenthecostofbrandandgenericplusthegenericcopayment.

Forallplansyoumustuseadesignatedretailormail-orderpharmacy.

RETAILCopayment for a 31-day Supply$10–Generic$30–PreferredBrand$45–Non-preferredBrand$45–SpecialtyDrugs

MAIL ORDER Copayment for a 90-day Supply$20–Generic$60–Brand$90–Non-preferredBrand$90–SpecialtyDrugs

Afterthemember’scopaymentstotal$4,350intheplanyear,copaymentsbecomethegreaterof$2.40or5%forgenericdrugsandbranddrugstreatedasgeneric.Foranyotherdrugs,thecopaymentsbecomethegreaterof$6or5%.

RETAIL PARTICIPATING PHARMACYCopayment for a 31-day Supply$10–Generic$30–PreferredBrand$45–Non-preferredBrand$45–SpecialtyDrugs

LOCAL PHARMACY (Must pick-up from pharmacy) Copayment for a 90-day Supply for a 2-month copay$20–Generic$60–PreferredBrand$90–Non-preferredBrand$90–SpecialtyDrugs

RETAIL PARTICIPATING PHARMACYCopayment for a 30-day Supply$10–Generic$30–PreferredBrandN/A–Non-preferredBrand$45–SpecialtyDrugs(Priorauthorizationrequired)

MAIL ORDER Copayment for a 90-day Supply$20–Generic$60–PreferredBrand$0–Non-PreferredBrand$90–SpecialtyDrugs(Priorauthorizationrequired)

RETAIL - Participating PharmacyCopayment for a 30-day Supply$10–Generic$30–PreferredBrand$45–Non-preferredBrand$45–SpecialtyDrugs(Priorauthorizationrequired)

MAIL ORDER - Participating Pharmacy Copayment for a 90-day Supply$20–Generic$60–PreferredBrand$90–Non-PreferredBrand$90–SpecialtyDrugs(Priorauthorizationrequired)

RETAIL - Non-Participating PharmacyCopayment for a 30-day SupplyGeneric 50%after$20copaymentPreferredBrand 50%after$20copaymentNon-preferredBrand 50%after$20copaymentSpecialtyDrugs(Priorauthorizationrequired) 50%after$20copayment

Vision Services •$0for1routineexampercalendaryear•$15foreachdiagnosticvisionexam•$0forpost-cataractsurgeryeyeglasslensesand/orcontactlenses(LimitedtotheMedicare-allowableamount)

Features:•$25foreachroutineeyeexam,limitedto1exameveryyear.•$25forannualglaucomascreeningforhigh-riskpatients•$25forsymptomaticophthalmologicservices•$0post-cataractsurgeryeyeglasslensesand/orcontactlensesrequiringintraocularlenses

•$50foreyeglassframesaftereachcataractsurgeryrequiringintraocularlenses.

Features:•$0copaymentforMedicare-coveredeyewear(onepairofeyeglassesorcontactlensesaftereachcataractsurgery)

•$25foreachMedicare-coveredeyeexam(diagnosisandtreatmentfordiseasesandconditionsoftheeye)

•$25forannualglaucomascreeningforhigh-riskpatients.

Visionscreenings$0copaymentforPrimaryCarePhysician-coverageformembersunderage18.

Features for all HMO members:•$3copaymentforroutineeyeexamevery12months•Copaymentsforframesandlensesarebasedonfeeschedule.

Features:•Visionscreeningsat$30copaymentwhenperformedbyprimaryphysi-cianor$50whenperformedbyaspecialistformembersunderage18.

Features:•Eligibleexpensesare40%afterannualdeductiblewhenperformedbyphysician.

DavisVisionValue-AddedDiscountProgramisofferedtoallmembers.Therearediscountsonallvisionservices,amail-ordercontactlensreplacementprogramanddiscountsonlaservisioncorrection.

Hearing Services $0for1routineexampercalendaryear$15-foreachdiagnostichearingexamHearing Aid AetnaPFFSwillreimburse$500forhearingaidsevery36months.

•$25foreachMedicare-coveredSpecialtyCarePhysicianhearingexam(diagnostichearingexams).

•Memberpayspay100%forroutinehearingexamandhearingaids.

• $25foreachMedicare-coveredhearingexam(diagnostichearingexams).•Memberpays100%forroutinehearingexams.•Uptoa30%discountforhearingaidsfromselectedproviders.

Hearingscreenings$0copaymentforPrimaryCarePhysicianvisit-coverageformembersunderage18.Oneaudiometricexamtodeterminetypeandextentofhearinglossonceevery36months.Planpays$1,000forhearingdeviceonceevery36months.

Hearingscreeningsat$30copaymentwhenperformedbyprimaryphysicianformembersunderage18.Not covered:Examsforhearingaids,hearing,speech,etc.

Eligibleexpensesat40%afterannualdeductiblewhenperformedbyphysi-cian.

Not covered:Examsforhearingaids,hearing,speech,etc.

Transplants $0foreachadmissionForallothertransplantservices(i.e.outpatientdiagnostic,lab,X-ray,outpatientphysicianvisits,etc.),themember’scopaymentisbasedonthetypeofserviceprovided.

• $912copaymentperconfinementthen100%coverageupto60days• $228additionalcopaymentperdaythen100%coveragefor61-90days• $456additionalcopaymentpereachlifetimereservedaythen100%cover-ageformaximum60lifetimereservedays

• $952copaymentperconfinementthen100%coverageupto60days• $238additionalcopaymentperdaythen100%coveragefor61-90days• $476additionalcopaymentpereachlifetimereserveday(then100%cover-ageformaximum60lifetimereservedays

PCP office:$20copaymentSpecialist:$45copaymentOutpatient facility:$200copaymentInpatient facility:$500copayment

Primary Doctor’s office: $30copaymentSpecialist: $50copaymentOutpatient facility:20%Inpatient facility:20%after$500copayment

Doctor’s office:40%afterannualdeductibleOutpatient facility: 40%afterannualdeductibleInpatient facility: 40%after$1,000copayment

What is the annual maximum out-of-pocket amount that I will pay?

What are the annual combined coinsurance/deductible maximum for the PPO? (Addallcoinsur-ance,deductiblesandeligiblecopayments)

ForAetnaPFFS,youwillalwayspaythecopaymentslistedinthechart.

Noannualout-of-pocketmaximum•Inpatientmentalhealthcare•Skillednursingfacility•Homehealthcare•Chiropracticservices•Podiatryservices•Outpatientmentalhealthcare•Outpatientsubstanceabusecare•Outpatientservices•Ambulanceservices•Emergencyservices•Urgentlyneededcare•Outpatientrehabilitationservices•Durablemedicalequipment•Prostheticdevices

•Cardiacrehabilitationservices•Renaldialysis•Diabeticself-monitoringtrainingandsupplies

•Comprehensiveoutpatientreha-bilitationfacility(CORF)

•Partialhospitalization•MedicarePartBoutpatientprescriptiondrugcopaymentsorcoinsurance

•CopaymentsforPrimaryPhysicians•Outpatientprescriptiondrugs•Allotherservicesnotlisted

Individual:$1,500Thefollowingservicesapply:

•Inpatienthospitalcare•Inpatientmentalhealthcare•Skillednursingfacility•Homehealthcare•Chiropracticservices•Podiatryservices•Outpatientmentalhealthcare

•Outpatientsubstanceabusecare•Outpatientservices•Ambulanceservices•Emergencyservices•Urgentlyneededcare•Outpatientrehabilitationservices•Durablemedicalequipment

•Prostheticdevices•Cardiacrehabilitationservices•Renaldialysis•Diabeticself-monitoringtrainingandsupplies•Comprehensiveoutpatientrehabilitationfacility(CORF)•Partialhospitalization•Diagnostictest,X-rays,andlabservices(TexasHealthSpringonly)

Theseout-of-pocketcostsdonotapply:

•MedicarePartBoutpatientprescriptiondrugcopaymentsorcoinsurance•CopaymentsforPCPsandspecialists

•Outpatientprescriptiondrugs•Allotherservicesnotlisted

Individual:$1,500Family: $3,000Excludingcopaysforprescriptiondrugs,inpatientmentalhealthandothersupplementalriders(e.g.Visioncare,prescriptiondruganddurablemedi-calequipment).

Individual: 3,000Family: $6,000Copaymentsarealwayspayable.

Individual: $5,000Family:$10,000Copaymentsarealwayspayable.

After I reach my annual out- of-pocket maximum, will I continue to pay any coinsurance or copay-ments?

Yes.Youwillalwayspaythelistedcopaymentsorcoinsuranceformedicalser-vices,prescriptiondrugs,andequipment.

Yes.YouwillalwayspaythecopaymentsorcoinsuranceforoutpatientprescriptiondrugsandPCP/specialistvisitsandanyotherservicesnotlistedabove.

Yes.Youwillalwayspaythecopaymentsorcoinsuranceforoutpatientpre-scriptiondrugsandPCP/specialistvisitsandanyotherservicesnotlistedabove.

Yes.Youwillalwayspaythecopaymentsorcoinsuranceforprescriptiondrugs,visioncare,durablemedicalequipment,inpatienthospitalstays,urgentcareandemergencyroomservices,etc.

Yes.Youwillalwayspaythecopaymentsforphysicianofficevisits,pre-scriptiondrugs,inpatienthospitalstays,urgentcareandemergencyroomservices.Youwillnotpaycoinsurance.

Yes.Youwillalwayspaythecopaymentsforphysicianofficevisits,pre-scriptiondrugs,inpatienthospitalstays,urgentcareandemergencyroomservices.Youwillnotpaycoinsurance.

May plan participants select physicians, specialists, and hospitals of their choice?

Yes.YoumayreceiveservicesfromanyprovidereligibletoreceiveMedicarereimbursementandwhoacceptstheAetnaPrivateFeeforServiceplan.

Theplanrecommendsyouselectaprimaryphysiciantodirectandcoordinateyourhealthcareneeds.

•Youmustgotonetworkdoctors,specialists,andhospitals.•Youmustchooseaprimarycarephysician(PCP).•AllcaremustbecoordinatedbyyourPCP.•PCPmustreferyoutootherprovidersandspecialistswhoareinthesamegroup.•Referralneededtogotonetworkhospitalsfornon-emergencycareandcertaindoctors,includingspecialists,forcertainservices.•Youdonotneedareferralwhenyouhaveamedicalemergency.Youshouldseektreatmentatthenearestmedicalfacility.•YoumaychangeyourPCPatanytime,thechangewillbeeffectivethefirstofthemonthfollowingyourrequesttochange.

Planparticipantsmustchooseprimarycarephysicians(PCP)andpharmaciesthatareintheHMOnetwork.AllcaremustbecoordinatedbyyourPCP.ThePCPmustreferyoutootherprovidersandspecialistswhoareinthesameIPAasthePCP.Femaleplanmembersmayself-refertoOB/GYNinthePCP’sgroupfortheirannualwell-womanexaminations.Note:ChangesintheselectionofyourPCPwillbeeffectivethefirstofthemonthafteryourequestthechange.

Planparticipantsmaychoosephysicians,hospitals,pharmaciesandothermedicalprovidersthataremembersofthePPOnetwork.ContactBCBSforassistanceinlocatingaproviderorvisitwww.bcbstx.com.

Participantsmaychooseaproviderout-of-network.ThedoctormaybeaParPlanprovidercontractedwithBCBStoprovidereducedordiscountedfees.

Participantsmayselecttheprovider,hospitalorpharmacyoftheirchoice.IftheproviderisnotinthePPOnetwork,thedoctormaybeaParPlanprovidercontractedwithBCBStoprovidereducedordiscountedfees.

Transportation N/A N/A $0copaymenttorecieve30one-waytripstoplan-approvedlocationseveryyear. N/A N/A

What is the lifetime maximum benefit per person? None None None None $1,500,000perparticipant.LifetimemaximumdoesnotapplytocoverageorservicesforAIDSorhumanimmunodeficiencyvirusinfection