Embed Size (px)
Citation preview
2018 - 2019
Everything you need to know aboutOpen Enrollment for Employees ofThe Texas A&M University System
Enrollment Period:July 1, 2018 - July 31, 2018
2 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
2019 BENEFITSOPEN ENROLLMENT GUIDE
NO CHANGES TO YOUR CURRENT ELECTIONS?If you don’t want to make any changes to your current benefits, you don’t need to do anything. Your current elections for these plans will automatically continue for plan year 2019. However, if you want a Health Care or Dependent Day Care Flexible Spending Account, you must enroll every year.
WHAT IF I WANT TO CHANGE MY ELECTIONS OR ENROLL FOR THE FIRST TIME?1. Go to Single Sign On (SSO) at https://sso.tamus.edu and log in. Click on the Workday link. You can review
your current benefits/premiums by clicking the Benefits Worklet and selecting Current Elections.2. You can change your benefits by clicking the Open Enrollment task in your Workday inbox. If you make a
change, don’t forget to SUBMIT. 3. If you make any benefit changes, you will receive an email confirmation in Workday. Review the summary and
be sure these are benefits you intended to elect for FY2019. Any changes you make during Open Enrollment will occur after September 1. Decisions made during Open Enrollment are binding through August 31, 2019, unless you have a qualified Life Event.
WHAT IF I HAVE A QUALIFIED LIFE EVENT IN FY2019?Dependents who become eligible during the year can be added to your coverage within 60 days of the qualified Life Event. Eligible dependents are your legal spouse, adopted, foster, stepchildren, and eligible grandchildren. Documentation will be required when you add a dependent.
Open Enrollment is an opportunity for you to review your current benefit plan elections to ensure they continue to meet your needs and those of your family. Review your benefits online by logging into Workday on the SSO menu (https://sso.tamus.edu). You can change your benefits, update your beneficiaries, check your mailing address, and add an email address online through Workday.
NEW FOR FY2019Employees and retirees will enter their benefit elections in Workday. Workday can be accessed by logging into SSO, and clicking the Workday link.
Navia Benefit Solutions will be replacing Payflex as the Flexible Spending Account (FSA) provider. The plan is very similar to the Payflex plan. The FY2019 Health Care FSA maximum is $2,650.
The CHI St. Joseph and Texas A&M Health Network, also known as the Brazos Valley Network, is a new network tier within the A&M Care plan with a $5 copay for a primary care physician, $15 copay for specialists, and 10% coinsurance for physicians and facilities contracted with CHI St. Joseph and Texas A&M. All other coverage will be the same. Although the new network benefits are available to all employees and retirees in the A&M Care Plan, the emphasis is in the Bryan-College Station area. The providers are located in the Brazos Valley area – Brazos, Austin, Burleson. Grimes, Leon, Lee, Leon, Madison, Robertson and Washington counties.
If you want to enroll in or increase your Optional or Dependent Life coverage, in most cases you must provide Evidence of Insurability (E of I). This year, you’ll choose your coverage and amount in Workday and receive a notice to wait until August 1. At that point you will receive an additional notice to return to Workday to answer your E of I questions. From that point, it should be just a short time until your E of I is approved or denied unless additional information is needed. In that case, your E of I will be approved or denied and become effective the first of the month following your receipt of notice.
A hearing aid benefit has been added to the A&M Care Plans. You can receive up to $1,000 per hearing aid per ear, every 3 years, subject to coinsurance. You will get more for your benefit if you use a network provider.
If you are a 9-11 month, full-time, monthly-paid benefit-eligible employee, your premiums will be prorated so that you pay for 12 months of premiums over 9 months. This means that you pay for 12 months of premiums by May 31.
If you are adding a dependent during Open Enrollment in Workday, please select the Reason for Adding which most closely represents your situation.
4 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
WELLNESS PREMIUM INCENTIVE CHANGES FOR NEXT YEAR
If you completed a wellness exam in the 2017-2018 plan year, you are already receiving the $30 premium reduction for 2018-2019. The annual exam is the only thing you will need to complete to receive the incentive for the 2018-2019 plan year.
Beginning September 1, 2018, you will need to complete a two-step process to receive the lowest insurance premium for the 2019-2020 plan year.
1. You still must complete your annual wellness exam. Preventive visits are no cost to you under the A&M Care Plan
2. You must also take a Health Assessment on MyEvive which will provide you with personalized information about available A&M System programs and wellness tools.
MyEvive will process both actions and you will receive your $30 premium credit. Your credit does not depend on participation in any of the suggested programs. There will no longer be $50 deductible credit for taking the Blue Cross Blue Shield Health Risk Assessment.
If you have not already registered for MyEvive, go online to https://tamus.myevive.com and enter your UIN and information from your BCBSTX insurance card. You may also download the MyEvive app on both Android and Apple devices and use the token code myevivetamus.
THE COST OF COVERAGE
All A&M Care plan premiums will remain the same. Remember that if you are changing to a different age bracket for life insurance, for example, 65-70, your premium may increase. The Long-Term Disability premium has decreased slightly from $.202 per $100 of monthly salary to $.178.
The Graduate Student Health Plan premiums have increased. Plan premiums are available on page 18. MDLive Virtual Visits are a new benefit for the Graduate Plan as well.
MDLIVE VIRTUAL VISITS
Virtual Visits is a new feature provided by MDLive through your Blue Cross and Blue Shield health plan.
This digitally-based solution provides cost-effective health care for simple, non-emergency medical and behavioral health conditions 24/7/365. It gives patients access to doctors and therapists in private, secure and confidential environments via telephone, online video or mobile app – no matter where the member lives.
Members select their doctor from a large, national virtual visit network and access customer support 24/7. When appropriate, prescriptions can be sent instantly to the member’s pharmacy of choice. Behavioral health consultations are available by appointment and video only.
Virtual Visits are included in the A&M Care plans with a $20 copay.
5 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
2018-2019 Open Enrollment Meeting Schedule
City Date Time Location System Member For
San Antonio 7/9 11:00AM-1:00PMCentral Academic Bldg, 1st Floor Lobby
One University Way, San Antonio, Texas 78224TAMU-San Antonio All
Killeen 7/10 9:00AM -12:00PMWarrior Hall - Multipurpose Room (1st Floor) 1001 Leadership Place, Killeen, Texas 76549
TAMU-Central Texas All
Canyon 7/1010:00AM-11:30AM
2:00PM-3:30PMANS, Rm 101
2505 4th Ave, Canyon, Texas 79016TAMU-West Texas All
Stephenville 7/11 8:30AM-3:00PMTarlton Student Center , Ballrooms A & B - Benefits Fair (Vendor Check-in),
Ballroom C -Meetings 1452 W. Jones Street, Stephenville, Texas 76402
TAMU-Tarleton All
Dallas 7/11 11:00AM-1:00PMBaylor College of Dentistry
3302 Gaston Ave, 6th FL Lobby, Dallas, Texas 75246HSC/BCD All
Commerce 7/12 9:00AM-12:00PMMcDowell Business Admin Bldg., Rm 343
2600 S. Neal, Commerce, Texas 75429TAMU-Commerce All
Texarkana 7/12 10:00AM-12:00PMUniversity Center Lounge Building
7101 University Avenue, Texarkana, Texas 75503TAMU-Texarkana All
Kingsville 7/16 10:00AM-2:00PMJavelina Dining Hall, Hall 2, Rm 200
1250 West Engineering Ave., Kingsville, Texas 78363TAMU-Kingsville All
Corpus Christi 7/17 11:00AM-2:00PMUniversity Center, Anchor Ballroom 147
6300 Ocean Dr., Corpus Christi, Texas 78412TAMU-Corpus Christi All
College Station 7/17 1:30PM-4:30PMAgriLife Sciences Building (AGLS), Rm 129
600 John Kimbrough Blvd., College Station, Texas 77843AgriLife All
Galveston 7/18 10:00AM-2:00PM Seibel Center Lobby TAMU-Galveston All
College Station 7/18 9:00AM-12:00PM Brazos Center3232 Briarcrest Dr, Bryan, TX 77802
TEES/COE, TTI, Agrilife, HSC Retirees
College Station 7/18 1:30PM-4:00PMGibb Gilchrist Bldg., Rm 103
2929 Research Pkwy, College Station, Texas 77843TTI Employees
Prairie View 7/19 9:00AM-4:00PMJohn B.Coleman Library, Public Events Rm 108700 University Drive, Prairie View, Texas 77446
Prairie View A&M University All
Laredo 7/199:00AM-12:00PM2:00PM-5:00PM
5201 University Blvd, Lardeo, Texas 78041 TAMIU-Laredo All
Houston 7/23 10:00AM-12:00PMInstitute of Biosciences and Technology, Rm 1119
2121 W. Holcombe Blvd, Houston, Texas 77030HSC/IBT-Houston All
College Station 7/24 9:00AM-11:30AMTEEX/TFS Headquarters, Conference Rm 1105 (A/B/C/D)
200 TechnologyWay, College Station, Texas 77845TEEX, Agrilife-TFS All
College Station 7/24 1:30PM-3:30PMEngineering Technologies Builidng (ETB)101 Bizzell St, College Station, TX 77843
TEES Employees
College Station 7/25 9:00AM-11:30AMMoore-Connally Bldg, 1st floor
301 Tarrow St., College Station, Texas 77840System Office All
Bryan 7/25 1:00PM-3:30PMHSC Bldg 1000, LL38
8447 Riverside Pkwy, Bryan, Texas77807Health Science Center Employees
Weslaco 7/25 10:00AM-12:00PMTAMU-Kingsville Citrus Center
312 N. International Blvd, Weslaco, Texas 78599TAMU-Weslaco All
College Station 7/26 12:00PM -1:30PMGeneral Services Complex (GSC), Rm 101 (A/B/C)750 Argronomy Rd, College Station, Texas 77843
TAMU Retirees
College Station 7/26 2:00PM-3:30PMGeneral Services Complex (GSC), Rm 101 (A/B/C)750 Argronomy Rd, College Station, Texas 77843
TAMU Employees
College Station 7/27 9:00AM-10:30AMGeneral Services Complex (GSC), Rm 101 (A/B/C)750 Argronomy Rd, College Station, Texas77843
TAMU Retirees
College Station 7/27 12:00PM-1:30PMGeneral Services Complex (GSC), Rm 101 (A/B/C)750 Argronomy Rd, College Station, Texas 77843
TAMU Employees
Lufkin 7/27 9:00AM-12:00PMAngelina Cooperative Extension Conference Room
2201 South Medford Drive, Lufkin, Texas 75901Texas Forest Service All
6 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with The Texas A&M University System and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things to know about your coverage and Medicare’s drug coverage:1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage
if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some offer more coverage for a higher premium.
2. The Texas A&M University System has determined that the prescription drug coverage offered by their plans is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?You can join when you first become eligible for Medicare, and each year from Oct. 15 to Dec. 7. However, if you lose your current creditable drug coverage through no fault of your own, you will also be eligible for a two month Special Enrollment Period to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide To Join A Medicare Drug Plan?If you decide to join a Medicare drug plan, your current A&M System coverage will be affected. You can be enrolled in both your System health plan and Medicare Part D, but you cannot receive prescription drug benefits from both plans. Your options include keeping your A&M System health coverage and not enrolling in Part D, or keeping your A&M System health coverage and enrolling in Part D. If you enroll in Part D, you will not receive a drug benefit from your System health plan, but your System health premiums will not decrease. If you decide to join a Medicare drug plan and drop your current coverage, which would mean your medical and drug coverage, you and your dependents will be able to get this coverage back during annual enrollment unless you are a “survivor”.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?If you drop or lose your current coverage with the A&M System and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. Your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…Contact your Human Resource Office listed at the back of this booklet for further information. You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the A&M System changes. You also may request a copy of this notice at any time. It is available from your Human Resources office or online at: http://www.tamus.edu/assets/files/benefits/pdf/Medicare_creditable_coverage_letter.pdf.
For More Information About Your Options Under Medicare Prescription Drug Coverage…More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage, visit www.medicare.gov; call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help OR call (800) MEDICARE ((800) 633-4227). TTY users should call (877) 486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information, visit Social Security on the web at www.socialsecurity.gov, or call them at (800) 772-1213 (TTY (800) 325-0778).
Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage
Important Notice about Your Prescription Drug Coverage and Medicare
Medicare Eligibility and EnrollmentWhen you, your spouse or other dependents become eligible for Medicare (by turning age 65 or by approval from Social Security to receive disability benefits), it is important to investigate enrollment in Medicare Parts A and B. In most cases, if you do not enroll in Medicare when you’re first eligible, you will have to pay a late enrollment penalty to Medicare for as long as you have Part B. For more information on Medicare Eligibility and Enrollment refer to Medicare.gov or call 1-800-Medicare (800) 633-4227).
Coordination of Benefits (COB)Medicare-Eligible RetireesIf you are retired, not working for the A&M System at 50% effort or more for at least 4½ consecutive months in a budgeted position and eligible for Medicare, you are considered Medicare-Primary for Coordination of Benefits (COB). That means all A&M plans pay benefits as if you are enrolled in Medicare Parts A and B. In addition, you will not be eligible for copayments.
You may enroll in A&M Care or the 65 PLUS Plan and use any provider. Plan benefits are calculated based on the total billed amount from your health provider. After Medicare pays, your A&M plan pays either the full benefit or the difference between the Blue Cross and Blue Shield allowed amount and the amount Medicare paid. This means that you receive full reimbursement in some cases. In the chart below is an example of the COB with Medicare and the A&M Care Plan if you have a $193 doctor’s office visit:
Medicare Primary (A&M Care Secondary) Plan year: January-December
A&M Care Primary (Medicare Secondary) Plan year: September-August
Primary Payer
Cost: $193Medicare Deductible: $183Remainder: $10Medicare pays 80%: $8Retiree pays 20%: $2Cost for retiree (deductible + 20%): $185
Once your Medicare deductible has been met for the plan year, you will just be responsible for the 20% coinsurance.
$20 or $30 copayment, depending on the provider
Secondary Payer
$193 is applied toward your $400 A&M Care deductible. If the A&M Care deductible has already been met, A&M Care will pay the $185.
$183 is applied to the Medicare deductible.
Medicare-Eligible Working RetireesIf you are a working retiree in a budgeted position at 50% effort or more for at least 4 ½ consecutive months, your A&M Care plan is primary and you will be eligible for office visit copayments.
Coordination of BenefitsThe chart below will help you determine whether Medicare is primary or secondary in various situations. The chart also includes information for covered spouses and dependents of the retiree.Retiree’s Status Dependent’s Status Eligible for the
65+ plan?Plan considered Primary for Retiree
Plan considered Primary for Dependents
If you are retired and not working for the TAMU System for 50% time or more for at least 4 ½ months (benefits-eligible position).Retiree is 65 or older or otherwise eligible for Medicare
Spouse/dependents are over 65 or otherwise eligible for Medicare
Yes Medicare Medicare
Retiree is 65 or older or otherwise eligible for Medicare
Spouse/dependents are under 65 or otherwise not eligible for Medicare
No Medicare A&M Care
Retiree is under 65 or otherwise not eligible for Medicare
Spouse/dependents are over 65 or otherwise eligible for Medicare
No A&M Care Medicare
Retiree is under 65 or otherwise not eligible for Medicare
Spouse/dependents are under 65 or otherwise not eligible for Medicare
No A&M Care A&M Care
If you are working for the TAMU System for 50% time or more for at least 4 ½ months (benefits-eligible position).Retiree* Spouse/dependents No A&M Care A&M Care
*If your terms of employment (percent effort or term months) change during the fiscal year, your primary/secondary status may change when coordinating benefits. Check with your Human Resources office if you are unsure of your status.
8 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
2018-2019 Plan: A&M Care InformationVendor: Blue Cross and Blue Shield of Texas (BCBSTX) This is a Preferred Provider Organization (PPO). Costs are higher if non-network providers are used. *Retirees age 65 and older are not eligible for copays.Member Services Contact Information: Blue Cross and Blue Shield of Texas 1 (866) 295-1212 Information about networks outside of Texas: 1 (800) 810-BLUE (2583) Website: http://www.bcbstx.com/tamus
Network; includes Brazos Valley Network (BVN) Non-NetworkLimitations and RestrictionsPre-existing condition limitations:
None
Benefit Maximum: NoneOut-of-service area restrictions:
Emergency care- must notify BCBSTX within 48 hours
Emergency care
Maximums and DeductiblesDeductibles: $400 Medical/$50 Rx $800 Medical/$400 hospitalizationOut-of-pocket maximum: $5,000 + the $400 medical deductible above
$10,000 + $1,200 family$10,000 + $800 deductible per person$20,000 + $2,400 family
Benefit maximum: No annual/lifetime maximums Except those listed belowHospital BenefitsIn-Hospital care: 20% after deductible; BVN-10% after deductible $400/adm. + deduct., then 50%Emergency Room: 20% after deductible; BVN-10% after deductible 20% after deductible if emergency;
otherwise 50% after deductibleSurgery: 20% after deductible; BVN-10% after deductible
In-physician’s office, See office visit50% after deductible50% after deductible
Non-Hospital Visits*Office visits: Primary Care Physician-$20/visit; BVN-$5/visit
Specialist-$30/visit; BVN-$15/visitCertain surgeries—20% after deductible
50% after deductible
Preventive exam: 100% covered Not coveredLab/X-rays: Benefit depends on setting & procedure 50% after deductibleSkilled nursing facility(not custodial care):
20% after deductible; 60-days/plan year 50% after deductible; 60-days/plan year
Home health care: 20% after deductible; 60-visits/plan year 50% after deductible; 60-visits/plan yearOther Healthcare Benefits*Chiropractic care: $30/visit; 30-visits/plan year; BVN-$15/visit 50% after deductible; 30-visits/plan year
Durable medical equipment: 20% after deductible; BVN-10% after deductible 50% after deductible*Maternity care: Hospital: 20% after deductible; BVN-10% after
deductibleDoctor: $30 initial visit only; BVN-$15 initial visit
Hospital: 50% after deductible;Doctor: 50% after deductible
*Mental health: Inpatient: 20% after deductible; BVN-10% after deductibleOutpatient: $20/visit; BVN-$5/visit
Inpatient: 50% after deductibleOutpatient: 50% after deductible
*Physical therapy: $30/visit; BVN-$15/visit 50% after deductible*Vision: $30/visit; BVN-$15/visit Routine preventive exams not coveredHearing: Illness/accident coverage; 20% coinsurance, hearing
aid up to $1000 per ear, every 3 yearsIllness/accident coverage only; 20% coinsurance, hearing aid up to $1000 per ear, every 3 years
Vendor: ExpressScriptsPrescription drugs: After you meet the $50/person/plan year prescription drug deductible (three-person maximum)• 30-day supply: $10/generic, $35/brand-name formulary, $60/brand-name non-formulary; brand-name copayment +
difference between brand name and generic when available• 90-day supply: Two copayments required if purchased by mail-order; three if purchased through most retail pharmacies
Member Services Contact Information: ExpressScripts: 1 (866) 544-6970 | Website: http://www.express-scripts.com
9 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
2018-2019 Plan: J Plan Health Care InformationVendor: Blue Cross and Blue Shield of Texas (BCBSTX)
The Texas A&M University Care J plan is only available to employees on a J Visa and their family members. The benefits are the same as those in the A&M Care plan, found in the Benefits Guide (http://www.tamus.edu/assets/files/benefits/pdf/GuideBooklet.pdf), including the BlueCross BlueShield in-network and out-of-network benefit differences found below. Since this coverage is a requirement of employment, if you are working for the A&M System on a J1 or J2 visa, the J plan will be your default plan.Graduate student employees on a J1/J2 Visa may also enroll in the Graduate Student plan, which meets the visa requirements for insurance coverage..
Member Services Contact Information: Blue Cross and Blue Shield of Texas 1 (866) 295-1212; Information about networks outside of Texas: 1 (800) 810-BLUE (2583) Website: http://www.bcbstx.com/tamus
Network; includes Brazos Valley Network (BVN) Non-NetworkLimitations and RestrictionsPre-existing condition limitations:
None
Out-of-service area restrictions:
Emergency care- must notify BCBSTX within 48 hours Emergency care
Maximums and DeductiblesDeductibles: $400 Medical/$50 Rx $800 Medical/$400 hospitalizationOut-of-pocket maximum:
$5,000 + the $400 medical deductible above$10,000 + $1,200 family
$10,000 + $800 deductible per person$20,000 + $2,400 family
Benefit maximum: No annual/lifetime maximums Except those listed belowHospital BenefitsIn-Hospital care: 20% after deductible; BVN-10% after deductible $400/adm. + deduct., then 50%Emergency Room: 20% after deductible; BVN-10% after deductible 20% after deductible if emergency;
otherwise 50% after deductibleSurgery: 20% after deductible; BVN-10% after deductible
In-physician’s office, See office visit50% after deductible50% after deductible
Non-Hospital VisitsOffice visits: Primary Care Physician-$20/visit; BVN-$5/visit
Specialist-$30/visit; BVN-$15/visitCertain surgeries—20% after deductible
50% after deductible
Preventive exam: 100% covered Not coveredLab/X-rays: Benefit depends on setting & procedure; See plan book or
call BCBSTX50% after deductible
Skilled nursing facility(not including custodial care):
20% after deductible; 60-days/plan year 50% after deductible; 60-days/plan year
Home health care: 20% after deductible; 60-visits/plan year 50% after deductible; 60-visits/plan yearReminder About Medical Evacuation & RepatriationRepatriation of remains of at least $25,000 and medical evacuation coverage of at least $50,000 are also required of those on a J-1 or J-2 visa. The student insurance plan for graduate and international students exceeds this federal requirement.The J plan does not provide these benefits; however, the Basic Life coverage from Minnesota Life, provided with the J plan as a package, does provide the following required coverage:• Evacuation/Repatriation: $150,000• Repatriation of Remains: $150,000• Visit of Family Member or Friend: $5,000• Return of Dependent Children: $5,000• Vehicle Return: $2,500With a combined single limit of $150,000 per person.Vendor: ExpressScriptsPrescription drugs: After you meet the $50/person/plan year prescription drug deductible (three-person maximum)• 30-day supply: $10/generic, $35/brand-name formulary, $60/brand-name non-formulary; brand-name copayment + difference
between brand-name and generic when available• 90-day supply: Two copayments required if purchased by mail-order; three if purchased through most retail pharmacies
Member Services Contact Information: ExpressScripts: 1 (866) 544-6970 | Website: http://www.express-scripts.com
2018-2019 Plan: Graduate Student Health Plan (SHP) InformationVendor: Blue Cross and Blue Shield of Texas (BCBSTX)
The Texas A&M University Care J plan is only available to employees on a J Visa and their family members. The benefits are the same as those in the A&M Care plan, found on pages 12 and beyond in the Benefits Guide (http://www.tamus.edu/assets/files/benefits/pdf/GuideBooklet.pdf), including the BlueCross BlueShield in-network and out-of-network benefit differences found below.Graduate student employees on a J1/J2 Visa who reside in the Bryan/College Station area may also enroll in the Graduate Student plan. The Grad plan meets their visa requirements. Since this coverage is a requirement of employment, if you are working for the A&M System on a J1 or J2 visa, the J plan will be your default plan.
Member Services Contact Information: Academic HealthPlans (AHP): 1 (877) 624-7911; Website: https://tamus.myahpcare.com/
Network Non-NetworkLimitations and RestrictionsPre-existing condition limitations:
None n/a
Out-of-service area restrictions: None n/aMaximums and DeductiblesDeductibles: $350 Medical/waived student health center $700; waived student health centerOut-of-pocket maximum: $6,350/person (includes all copayments) $12,700/person (includes all copayments)Benefit maximum: No annual/lifetime maximumsHospital BenefitsIn-Hospital care: 20% after deductible 40% after deductibleEmergency Room: Emergency Room Physician:
20% after $150 copayment20% after deductible
Surgery: 20% after deductible 40% after deductibleNon-Hospital VisitsOffice visits: $35 copay 40% after $35 copayment Preventive exam: 100% covered 40% after deductibleLab/X-rays: 20% after deductible 40% after deductibleSkilled nursing facility(not including custodial care):
20% after deductible; 25 days/plan year 40% after deductible; 25 days/plan year
Home health care: 20% after deductible; 60 visits/plan year 40% after deductible; 60 visits/plan yearOther Healthcare BenefitsChiropractic care: $35/visit; 35 visits/person 40% after $35 copay; 35 visits/personDurable medical equipment: 20% after deductible 40% after deductible Mental health: Inpatient - 20% after deductible
Outpatient - $35/visit40% after deductible40% after $35 copay
Physical therapy: $35/visit; 35 visits/person 40% after $35 copay; 35 visits/personVision/Hearing: 20% after deductible
One preventive vision exam/per plan year40% after deductible
Prescription drugs: $15 at student health center;Prime Therapeutics RX drug card $15/generic, $30/preferred brand-name$40/non-preferred brand-name - no maximumGeneric Drug –A medication duplicated by another company once the patent expiresBrand Name Drug –A medication developed by a pharmaceutical company
1
of 7
Sum
mar
y of B
enef
its an
d Co
vera
ge: W
hat th
is Pl
an C
over
s & W
hat Y
ou P
ay F
or C
over
ed S
ervic
es
Cove
rage
Per
iod:
06/15
/2018
– 08
/31/20
18
Texa
s A&M
Uni
vers
ity S
yste
m: A
&M C
are P
lan
Co
vera
ge fo
r: Ind
ividu
al +
Fami
ly | P
lan T
ype:
PPO
The S
umm
ary o
f Ben
efits
and
Cove
rage
(SBC
) doc
umen
t will
help
you
choo
se a
healt
h pl
an. T
he S
BC sh
ows y
ou h
ow yo
u an
d th
e plan
wou
ld
shar
e the
cost
for c
over
ed h
ealth
care
serv
ices.
NOTE
: Inf
orm
atio
n ab
out t
he co
st o
f thi
s plan
(call
ed th
e pre
miu
m) w
ill be
pro
vided
sepa
rate
ly.
This
is on
ly a s
umm
ary.
For m
ore i
nform
ation
abou
t you
r cov
erag
e, or
to ge
t a co
py of
the c
omple
te ter
ms of
cove
rage
, call
1-86
6-29
5-12
12 or
visit
ww
w.bc
bstx.
com/
tamus
. For
gene
ral d
efinit
ions o
f com
mon t
erms
, suc
h as a
llowe
d amo
unt,
balan
ce bi
lling,
coins
uran
ce, c
opay
ment,
dedu
ctible
, pro
vider
, or o
ther
unde
rlined
term
s see
the G
lossa
ry. Y
ou ca
n view
the G
lossa
ry at
www.
cms.g
ov/C
CIIO
/Res
ource
s/For
ms-R
epor
ts-an
d-Ot
her-R
esou
rces/D
ownlo
ads/U
G-Gl
ossa
ry-50
8-MM
.pdf o
r call
1-86
6-29
5-12
12 to
requ
est a
copy
.
Impo
rtant
Que
stio
ns
Answ
ers
Why
Thi
s Mat
ters
:
Wha
t is th
e ove
rall
dedu
ctible
?
Braz
os V
alley
Netw
ork:
$400
Indiv
idual
/$1,20
0 Fam
ily
In-Ne
twor
k: $4
00 In
dividu
al / $
1,200
Fam
ily
Out-o
f-Netw
ork:
$800
Indiv
idual
/ $2,4
00 F
amily
Gene
rally
, you
mus
t pay
all o
f the c
osts
from
prov
iders
up to
the d
educ
tible
amou
nt be
fore t
his pl
an be
gins t
o pay
. If yo
u hav
e othe
r fami
ly me
mber
s on t
he
plan,
each
fami
ly me
mber
mus
t mee
t their
own i
ndivi
dual
dedu
ctible
until
the
total
amou
nt of
dedu
ctible
expe
nses
paid
by al
l fami
ly me
mber
s mee
ts the
ov
erall
fami
ly de
ducti
ble.
Are t
here
serv
ices
cove
red b
efore
you
mee
t you
r ded
uctib
le?
Yes.
Servi
ces t
hat c
harg
e a co
pay,
pres
cripti
on dr
ugs,
and
Braz
os V
alley
Netw
ork &
In-N
etwor
k pre
venti
ve ca
re an
d dia
gnos
tic te
sts ar
e cov
ered
befor
e you
mee
t you
r de
ducti
ble.
This
plan c
over
s som
e item
s and
servi
ces e
ven i
f you
have
n’t ye
t met
the
dedu
ctible
amou
nt. B
ut a c
opay
ment
or co
insur
ance
may
apply
. For
exam
ple,
this p
lan co
vers
certa
in pr
even
tive s
ervic
es w
ithou
t cos
t sha
ring a
nd be
fore y
ou
meet
your
dedu
ctible
. See
a lis
t of c
over
ed pr
even
tive s
ervic
es at
ww
w.he
althc
are.g
ov/co
vera
ge/pr
even
tive-
care
-ben
efits/
. Ar
e the
re ot
her
dedu
ctible
s for
spec
ific
serv
ices?
Yes.
Out-o
f-Netw
ork:
$400
non-
emer
genc
y hos
pital
admi
ssion
. $50
Rx d
educ
tible
Braz
os V
alley
, In-,
and
Out-o
f-Netw
ork.
Ther
e are
no ot
her s
pecif
ic de
ducti
bles.
You m
ust p
ay al
l of th
e cos
ts for
thes
e ser
vices
up to
the s
pecif
ic de
ducti
ble
amou
nt be
fore t
his pl
an be
gins t
o pay
for th
ese s
ervic
es.
Wha
t is th
e out
-of-
pock
et lim
it for
this
plan?
Braz
os V
alley
Netw
ork:
$5,00
0 Per
son +
$400
Med
ical
dedu
ctible
/ $10
,000 F
amily
+ $1
,200 M
edica
l ded
uctib
le In-
Netw
ork:
$5,00
0 Per
son +
$400
Med
ical d
educ
tible
/ $1
0,000
Fam
ily +
$1,20
0 Med
ical d
educ
tible
Out-o
f-Netw
ork:
$10,0
00 P
erso
n + $8
00 M
edica
l de
ducti
ble / $
20,00
0 Fam
ily +
$2,40
0 Med
ical d
educ
tible
The o
ut-of-
pock
et lim
it is t
he m
ost y
ou co
uld pa
y in a
year
for c
over
ed se
rvice
s. If y
ou ha
ve ot
her f
amily
mem
bers
in thi
s plan
, they
have
to m
eet th
eir ow
n out-
of-po
cket
limits
until
the ov
erall
fami
ly ou
t-of-p
ocke
t limi
t has
been
met.
Wha
t is no
t inclu
ded i
n th
e out
-of-p
ocke
t lim
it?
Prem
iums,
prea
uthor
izatio
n pen
alties
, bala
nced
-bille
d ch
arge
s, an
d hea
lthca
re th
is pla
n doe
sn’t c
over
. Ev
en th
ough
you p
ay th
ese e
xpen
ses,
they d
on’t c
ount
towar
d the
out-o
f-poc
ket
limit
Will
you p
ay le
ss if
you
use a
netw
ork
prov
ider?
Ye
s. Se
e www
.bcbs
tx.co
m/tam
us o
r call
1-80
0-52
1-22
27
for a
list o
f netw
ork p
rovid
ers.
You p
ay th
e lea
st if y
ou us
e a pr
ovide
r in B
razo
s Vall
ey N
etwor
k. Yo
u pay
mor
e if y
ou us
e a pr
ovide
r in-n
etwor
k. Yo
u will
pay t
he m
ost if
you u
se an
out-o
f-ne
twor
k pro
vider
, and
you m
ight r
eceiv
e a bi
ll fro
m a p
rovid
er fo
r the
diffe
renc
e be
twee
n the
prov
ider’s
char
ge an
d wha
t you
r plan
pays
(bala
nce b
illing)
. Be
awar
e, yo
ur ne
twor
k pro
vider
migh
t use
an ou
t-of-n
etwor
k pro
vider
for s
ome
servi
ces (
such
as la
b wor
k). C
heck
with
your
prov
ider b
efore
you g
et se
rvice
s. Do
you n
eed a
refer
ral
to se
e a sp
ecial
ist?
No.
You c
an se
e the
spec
ialist
you c
hoos
e with
out a
refer
ral.
\
2
of 7
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see t
he pl
an or
polic
y doc
umen
t at w
ww.bc
bstx.
com/
tamus
.
All c
opay
men
t and
coin
sura
nce c
osts
show
n in t
his ch
art a
re af
ter yo
ur d
educ
tible
has b
een m
et, if
a ded
uctib
le ap
plies
.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
Wha
t You
Will
Pay
Lim
itatio
ns, E
xcep
tions
, &
Othe
r Im
porta
nt In
form
atio
n Br
azos
Vall
ey
Prov
ider
(You
will
pay t
he le
ast)
In-Ne
twor
k Pro
vider
Ou
t-of-N
etwor
k Pr
ovide
r (Y
ou w
ill pa
y the
mos
t)
If yo
u vis
it a
healt
h ca
re
prov
ider
’s of
fice
or cl
inic
Prim
ary c
are v
isit to
trea
t an i
njury
or ill
ness
$5
copa
y/visi
t; de
ducti
ble do
es no
t ap
ply
$20 c
opay
/visit
; de
ducti
ble do
es no
t ap
ply
50%
coins
uran
ce
after
dedu
ctible
No
ne
Spec
ialist
visit
$1
5 cop
ay/vi
sit;
dedu
ctible
does
not
apply
$30 c
opay
/visit
; de
ducti
ble do
es no
t ap
ply
50%
coins
uran
ce
after
dedu
ctible
No
ne
Prev
entiv
e car
e/scre
ening
/ im
muniz
ation
No
Cha
rge;
dedu
ctible
does
not
apply
No C
harg
e;
dedu
ctible
does
not
apply
No
t Cov
ered
You m
ay ha
ve to
pay f
or se
rvice
s tha
t are
n’t pr
even
tive.
Ask y
our
prov
ider if
the s
ervic
es ne
eded
are
prev
entiv
e. Th
en ch
eck w
hat y
our
plan w
ill pa
y for
.
If yo
u ha
ve a
test
Diag
nosti
c tes
t (x-r
ay, b
lood w
ork)
No C
harg
e;
de
ducti
ble do
es no
t ap
ply
No C
harg
e;
de
ducti
ble do
es no
t ap
ply
50%
coins
uran
ce
after
dedu
ctible
Of
fice v
isit c
opay
may
apply
.
Imag
ing (C
T/PE
T sc
ans,
MRIs)
10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
Certa
in Di
agno
stic P
roce
dure
s on
ly. S
ee yo
ur po
licy o
r plan
do
cume
nt for
a lis
t of p
roce
dure
s.
Prea
uthor
izatio
n may
be re
quire
d.
3
of 7
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see t
he pl
an or
polic
y doc
umen
t at w
ww.bc
bstx.
com/
tamus
.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
Wha
t You
Will
Pay
Lim
itatio
ns, E
xcep
tions
, &
Othe
r Im
porta
nt
Info
rmat
ion
Braz
os V
alley
Pro
vider
(Y
ou w
ill pa
y the
leas
t) In-
Netw
ork P
rovid
er
Out-o
f-Netw
ork P
rovid
er
(You
will
pay t
he m
ost)
If yo
u ne
ed d
rugs
to
trea
t you
r illn
ess o
r co
nditi
on
More
infor
matio
n ab
out p
resc
riptio
n dr
ug co
vera
ge is
av
ailab
le at
www.
expr
esss
cripts
.com
Gene
ric dr
ugs
Retai
l: $10
copa
y afte
r $5
0 ded
uctib
le
Ma
il: $2
0 cop
ay a
fter
$50 d
educ
tible
Retai
l: $10
copa
y aft
er $5
0 ded
uctib
le
Ma
il: $2
0 cop
ay a
fter
$50 d
educ
tible
Total
cost
of pr
escri
ption
at
the tim
e of s
ervic
e. 75
% of
all
owab
le ch
arge
s are
re
imbu
rsed a
fter d
educ
tible
and a
pplic
able
copa
ymen
t.
Retai
l: one
copa
y per
30
day s
upply
Mail:
two c
opay
s up t
o 90
day s
upply
Pr
eferre
d bra
nd dr
ugs
Retai
l: $35
copa
y afte
r $5
0 ded
uctib
le
Ma
il: $7
0 cop
ay af
ter
$50 d
educ
tible
Retai
l: $35
copa
y aft
er $5
0 ded
uctib
le
Ma
il: $7
0 cop
ay af
ter
$50 d
educ
tible
Total
cost
of pr
escri
ption
at
the tim
e of s
ervic
e. 75
% of
all
owab
le ch
arge
s are
re
imbu
rsed a
fter d
educ
tible
and a
pplic
able
copa
ymen
t.
Non-
prefe
rred b
rand
drug
s Re
tail: $
60 co
pay a
fter
$50 d
educ
tible
Mail:
$120
copa
y afte
r $5
0 ded
uctib
le
Retai
l: $60
copa
y aft
er $5
0 ded
uctib
le
Ma
il: $1
20 co
pay a
fter
$50 d
educ
tible
Total
cost
of pr
escri
ption
at
the tim
e of s
ervic
e. 75
% of
all
owab
le ch
arge
s are
re
imbu
rsed a
fter d
educ
tible
and a
pplic
able
copa
ymen
t.
Spec
ialty
drug
s
Gene
ric $1
0 cop
ay
Prefe
rred $
35 co
pay
Non-
prefe
rred $
60
copa
y afte
r $50
de
ducti
ble
Gene
ric $1
0 cop
ay
Prefe
rred $
35 co
pay
Non-
prefe
rred $
60
copa
y afte
r $50
de
ducti
ble
Total
cost
of pr
escri
ption
at
the tim
e of s
ervic
e. 75
% of
all
owab
le ch
arge
s are
re
imbu
rsed a
fter d
educ
tible
and a
pplic
able
copa
ymen
t.
Begin
ning w
ith se
cond
fill
spec
ialty
medic
ation
mus
t be
filled
thro
ugh S
pecia
lty
Phar
macy
: one
copa
ymen
t pe
r 30 d
ay su
pply
If yo
u ha
ve
outp
atien
t sur
gery
Facil
ity fe
e (e.g
., amb
ulator
y su
rger
y cen
ter)
10%
coins
uran
ce
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
None
Phys
ician
/surg
eon f
ees
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
50%
coins
uran
ce
after
dedu
ctible
No
ne
If yo
u ne
ed
imm
ediat
e m
edica
l atte
ntio
n
Emer
genc
y roo
m ca
re
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
No
ne
Emer
genc
y med
ical tr
ansp
ortat
ion
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
No
ne
Urge
nt ca
re
$5/$1
5 cop
ay/vi
sit;
dedu
ctible
does
not
apply
$20/$
30 co
pay/v
isit;
dedu
ctible
does
not
apply
50
% co
insur
ance
aft
er de
ducti
ble
None
4
of 7
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see t
he pl
an or
polic
y doc
umen
t at w
ww.bc
bstx.
com/
tamus
.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
W
hat Y
ou W
ill Pa
y Li
mita
tions
, Exc
eptio
ns, &
Ot
her I
mpo
rtant
Info
rmat
ion
Braz
os V
alley
Pro
vider
(Y
ou w
ill pa
y the
leas
t) In-
Netw
ork P
rovid
er
Out-o
f-Netw
ork P
rovid
er
(You
will
pay t
he m
ost)
If yo
u ha
ve a
hosp
ital s
tay
Facil
ity fe
e (e.g
., hos
pital
room
) 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50%
coins
uran
ce af
ter
dedu
ctible
plus
$400
per
occu
rrenc
e ded
uctib
le for
no
n-em
erge
ncy a
dmiss
ion
All n
on-e
merg
ency
servi
ces m
ust
be pr
eauth
orize
d; $5
00 pe
nalty
if no
t pre
autho
rized
In-N
etwor
k or
Out-o
f-Netw
ork.
Phys
ician
/surg
eon f
ees
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
50%
coins
uran
ce
after
dedu
ctible
No
ne
If yo
u ne
ed
men
tal h
ealth
, be
havio
ral
healt
h, o
r su
bsta
nce a
buse
se
rvice
s
Outpa
tient
servi
ces
$5 co
pay/o
ffice v
isit;
dedu
ctible
does
not
apply
10
% co
insur
ance
for
other
outpa
tient
servi
ces
$20 c
opay
/offic
e vis
it; de
ducti
ble
does
not a
pply
20%
coins
uran
ce
for ot
her o
utpati
ent
servi
ces
50%
coins
uran
ce
after
dedu
ctible
Ce
rtain
servi
ces m
ust b
e pr
eauth
orize
d; re
fer to
plan
do
cume
nt.
Inpati
ent s
ervic
es
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
50%
coins
uran
ce af
ter
dedu
ctible
plus
$400
per
occu
rrenc
e ded
uctib
le for
no
n-em
erge
ncy a
dmiss
ion
All n
on-e
merg
ency
servi
ces m
ust
be pr
eauth
orize
d; $5
00 pe
nalty
if no
t pre
autho
rized
In-N
etwor
k or
Out-o
f-Netw
ork.
If yo
u ar
e pr
egna
nt
Offic
e visi
ts $5
/$15 c
opay
/initia
l vis
it; de
ducti
ble do
es
not a
pply
$20/$
30 co
pay/i
nitial
vis
it; de
ducti
ble
does
not a
pply
50%
coins
uran
ce
after
dedu
ctible
Spec
ialist
has h
igher
copa
y. No
Ch
arge
after
initia
l cop
ay. F
or
phys
ician
servi
ces o
nly.
Co
st sh
aring
does
not a
pply
for
prev
entiv
e ser
vices
. Dep
endin
g on
the t
ype o
f ser
vices
, a
copa
ymen
t, coin
sura
nce,
or
dedu
ctible
may
apply
. Mate
rnity
ca
re m
ay in
clude
tests
and
servi
ces d
escri
bed e
lsewh
ere i
n the
SBC
(i.e.
ultra
soun
d).
Child
birth/
deliv
ery p
rofes
siona
l se
rvice
s 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
Child
birth/
deliv
ery f
acilit
y se
rvice
s 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50%
coins
uran
ce af
ter
dedu
ctible
plus
$400
per
occu
rrenc
e ded
uctib
le for
no
n-em
erge
ncy a
dmiss
ion
All n
on-e
merg
ency
servi
ces m
ust
be pr
eauth
orize
d; $5
00 pe
nalty
if no
t pre
autho
rized
In-N
etwor
k or
Out-o
f-Netw
ork.
5
of 7
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see t
he pl
an or
polic
y doc
umen
t at w
ww.bc
bstx.
com/
tamus
.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
W
hat Y
ou W
ill Pa
y Li
mita
tions
, Exc
eptio
ns, &
Ot
her I
mpo
rtant
Info
rmat
ion
Braz
os V
alley
Pro
vider
(Y
ou w
ill pa
y the
leas
t) In-
Netw
ork P
rovid
er
Out-o
f-Netw
ork P
rovid
er
(You
will
pay t
he m
ost)
If yo
u ne
ed
help
re
cove
ring
or
have
oth
er
spec
ial h
ealth
ne
eds
Home
healt
h car
e 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
All se
rvice
s mus
t be p
reauth
orize
d. Lim
ited t
o 60 v
isits
per p
lan ye
ar.
Reha
bilita
tion s
ervic
es
$15 c
opay
/visit
; de
ducti
ble do
es no
t app
ly $3
0 cop
ay/vi
sit;
dedu
ctible
does
not a
pply
50%
coins
uran
ce
after
dedu
ctible
No
ne
Habil
itatio
n ser
vices
$1
5 cop
ay/vi
sit;
dedu
ctible
does
not a
pply
$30 c
opay
/visit
; de
ducti
ble do
es no
t app
ly 50
% co
insur
ance
aft
er de
ducti
ble
None
Skille
d nur
sing c
are
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
50%
coins
uran
ce
after
dedu
ctible
All
servi
ces m
ust b
e prea
uthori
zed.
Limite
d to 6
0 day
s per
plan y
ear.
Dura
ble m
edica
l equ
ipmen
t 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
None
Hosp
ice se
rvice
s 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
All se
rvice
s mus
t be p
reauth
orize
d.
No
plan
max
imum
s.
If yo
ur ch
ild
need
s den
tal
or ey
e car
e
Child
ren’s
eye e
xam
$15 c
opay
/visit
;
dedu
ctible
does
not a
pply
$30 c
opay
/visit
; de
ducti
ble do
es no
t app
ly 50
% co
insur
ance
aft
er de
ducti
ble
None
Child
ren’s
glas
ses
Not C
over
ed
Not C
over
ed
Not C
over
ed
None
Child
ren’s
denta
l che
ck-u
p No
t Cov
ered
No
t Cov
ered
No
t Cov
ered
No
ne
Exclu
ded
serv
ices &
Oth
er C
over
ed S
ervic
es:
Serv
ices Y
our P
lan G
ener
ally D
oes N
OT C
over
(Che
ck yo
ur p
olicy
or p
lan d
ocum
ent f
or m
ore i
nfor
mat
ion
and
a list
of a
ny o
ther
exclu
ded
serv
ices.)
•
Cosm
etic s
urge
ry
• De
ntal c
are (
Adult
) •
Infer
tility
treatm
ent
• Lo
ng-te
rm ca
re
• Ro
utine
foot
care
(cov
ered
only
with
diagn
osis
of dia
betes
) •
Weig
ht los
s pro
gram
s (ex
cept
Natur
ally S
lim pr
ogra
m)
Othe
r Cov
ered
Ser
vices
(Lim
itatio
ns m
ay ap
ply t
o th
ese s
ervic
es. T
his i
sn’t
a com
plet
e list
. Plea
se se
e you
r plan
doc
umen
t.)
• Ac
upun
cture
(limi
tation
s may
apply
) •
Baria
tric su
rger
y (lim
itatio
ns m
ay ap
ply)
• Ch
iropr
actic
care
(limi
tation
s may
apply
)
• He
aring
aids
•
Non-
emer
genc
y car
e whe
n tra
velin
g outs
ide th
e U.S
. •
Priva
te-du
ty nu
rsing
•
Routi
ne ey
e car
e (Ad
ult V
ision
Scre
ening
)
6
of 7
Your
Rig
hts t
o Co
ntin
ue C
over
age:
The
re ar
e age
ncies
that
can h
elp if
you w
ant to
conti
nue y
our c
over
age a
fter it
ends
. The
conta
ct inf
orma
tion f
or th
ose
agen
cies i
s: the
plan
at 1-
866-
295-
1212
, U.S
. Dep
artm
ent o
f Lab
or’s
Emplo
yee B
enefi
ts Se
curity
Adm
inistr
ation
at 1
-866
-444
-EBS
A (3
272)
or
www.
dol.g
ov/eb
sa/he
althr
eform
, or D
epar
tmen
t of H
ealth
and H
uman
Ser
vices
, Cen
ter fo
r Con
sume
r Info
rmati
on an
d Ins
uran
ce O
versi
ght, a
t 1-8
77-2
67-2
323
x615
65 or
www
.cciio
.cms.g
ov. O
ther c
over
age o
ption
s may
be av
ailab
le to
you t
oo, in
cludin
g buy
ing in
dividu
al ins
uran
ce co
vera
ge th
roug
h the
Hea
lth In
sura
nce
Marke
tplac
e. Fo
r mor
e info
rmati
on ab
out th
e Ma
rketpl
ace,
visit w
ww.H
ealth
Care
.gov o
r call
1-80
0-31
8-25
96.
Your
Grie
vanc
e and
App
eals
Righ
ts: T
here
are a
genc
ies th
at ca
n help
if yo
u hav
e a co
mplai
nt ag
ainst
your
plan
for a
denia
l of a
claim
. This
comp
laint
is ca
lled a
gr
ievan
ce or
appe
al. F
or m
ore i
nform
ation
abou
t you
r righ
ts, lo
ok at
the e
xplan
ation
of be
nefits
you w
ill re
ceive
for t
hat m
edica
l clai
m. Y
our p
lan do
cume
nts al
so
prov
ide co
mplet
e info
rmati
on to
subm
it a cl
aim, a
ppea
l, or a
griev
ance
for a
ny re
ason
to yo
ur p
lan. F
or m
ore i
nform
ation
abou
t you
r righ
ts, th
is no
tice,
or as
sistan
ce,
conta
ct: B
lue C
ross
and B
lue S
hield
of Te
xas a
t 1-8
66-2
95-1
212 o
r visi
t www
.bcbs
tx.co
m, or
conta
ct the
U.S
. Dep
artm
ent o
f Lab
or's
Emplo
yee B
enefi
ts Se
curity
Ad
minis
tratio
n at 1
-866
-444
-EBS
A (3
272)
or vi
sit w
ww.do
l.gov
/ebsa
/healt
hrefo
rm. A
dditio
nally
, a co
nsum
er as
sistan
ce pr
ogra
m ca
n help
you f
ile yo
ur ap
peal.
Co
ntact
the T
exas
Dep
artm
ent o
f Insu
ranc
e's C
onsu
mer H
ealth
Ass
istan
ce P
rogr
am at
1-8
00-2
52-3
439 o
r visi
t www
.texa
shea
lthop
tions
.com.
Do
es th
is pl
an p
rovid
e Min
imum
Ess
entia
l Cov
erag
e? Y
es
If you
don’t
have
Mini
mum
Esse
ntial
Cove
rage
for a
mon
th, yo
u’ll h
ave t
o ma
ke a
paym
ent w
hen y
ou fil
e you
r tax
retur
n un
less y
ou qu
alify
for an
exem
ption
from
the
requ
ireme
nt tha
t you
have
healt
h cov
erag
e for
that
month
. Do
es th
is pl
an m
eet t
he M
inim
um V
alue S
tand
ards
? Ye
s If y
our p
lan do
esn’t
mee
t the M
inimu
m Va
lue S
tanda
rds,
you m
ay be
eligi
ble fo
r a pr
emium
tax c
redit
to he
lp yo
u pay
for a
plan
thro
ugh t
he M
arke
tplac
e. La
ngua
ge A
cces
s Ser
vices
: Sp
anish
(Esp
añol)
: Par
a obte
ner a
sisten
cia en
Esp
añol,
llame
al 1-
866-
295-
1212
. Ta
galog
(Tag
alog)
: Kun
g kail
anga
n niny
o ang
tulon
g sa T
agalo
g tum
awag
sa 1-
866-
295-
1212
. Ch
inese
(中文
): 如果需要中文的帮助，请拨打这个号码
1-86
6-29
5-12
12.
Nava
jo (D
ine):
Dine
k'ehg
o shik
a at'o
hwol
ninisi
ngo,
kwiiji
go ho
lne' 1
-866
-295
-121
2.
––––
––––
––––
––––
––––
––To
see
exam
ples o
f how
this
plan
migh
t cov
er co
sts fo
r a sa
mple
med
ical s
ituat
ion, s
ee th
e ne
xt se
ction
.–––
––––
––––
––––
––––
–––
7
of 7
The p
lan w
ould
be re
spon
sible
for th
e othe
r cos
ts of
these
EXA
MPLE
cove
red s
ervic
es.
Peg
is Ha
ving
a Bab
y (9
mon
ths of
in-n
etwor
k pre
-nata
l car
e and
a ho
spita
l deli
very)
Mia’s
Sim
ple F
ract
ure
(in-n
etwor
k eme
rgen
cy ro
om vi
sit an
d foll
ow
up ca
re)
Mana
ging
Joe’s
type
2 Di
abet
es
(a ye
ar of
routi
ne in
-netw
ork c
are o
f a w
ell-
contr
olled
cond
ition)
T
he p
lan’s
over
all d
educ
tible
$4
00
S
pecia
list c
opay
men
ts
$15
H
ospi
tal (
facil
ity) c
oins
uran
ce
10%
Oth
er co
insu
ranc
e 10
%
This
EXAM
PLE
even
t inc
lude
s ser
vices
like:
Sp
ecial
ist of
fice v
isits
(pre
nata
l car
e)
Child
birth/
Deliv
ery P
rofes
siona
l Ser
vices
Ch
ildbir
th/De
liver
y Fac
ility S
ervic
es
Diag
nosti
c tes
ts (u
ltras
ound
s and
bloo
d wo
rk)
Spec
ialist
visit
(ane
sthes
ia)
Tota
l Exa
mpl
e Cos
t $1
2,800
In
this
exam
ple,
Peg
woul
d pa
y:
Cost
shar
ing
Dedu
ctible
s $4
00
Copa
ymen
ts $5
0 Co
insur
ance
$1
,100
Wha
t isn’t
cove
red
Limits
or ex
clusio
ns
$60
The t
otal
Peg
woul
d pa
y is
$1,61
0
T
he p
lan’s
over
all d
educ
tible
$4
00
S
pecia
list c
opay
men
ts
$15
H
ospi
tal (
facil
ity) c
oins
uran
ce
10%
Oth
er co
insu
ranc
e 10
%
This
EXAM
PLE
even
t inc
lude
s ser
vices
like:
Pr
imar
y car
e phy
sician
offic
e visi
ts (in
cludin
g dis
ease
edu
catio
n)
Diag
nosti
c tes
ts (b
lood
work
) Pr
escri
ption
drug
s Du
rable
med
ical e
quipm
ent (
gluco
se m
eter
) To
tal E
xam
ple C
ost
$7,40
0 In
this
exam
ple,
Joe w
ould
pay
: Co
st sh
aring
De
ducti
bles*
$4
50
Copa
ymen
ts $8
00
Coins
uran
ce
$100
W
hat is
n’t co
vere
d Lim
its or
exclu
sions
$6
0 Th
e tot
al Jo
e wou
ld p
ay is
$1
,410
T
he p
lan’s
over
all d
educ
tible
$400
Spe
cialis
t cop
aym
ents
$1
5
Hos
pita
l (fa
cility
) coi
nsur
ance
1
0%
O
ther
coin
sura
nce
10%
Th
is EX
AMPL
E ev
ent i
nclu
des s
ervic
es lik
e:
Emer
genc
y roo
m ca
re (in
cludin
g m
edica
l su
pplie
s) Di
agno
stic t
est (
x-ra
y)
Dura
ble m
edica
l equ
ipmen
t (cru
tches
) Re
habil
itatio
n ser
vices
(phy
sical
ther
apy)
To
tal E
xam
ple C
ost
$1,90
0 In
this
exam
ple,
Mia w
ould
pay
: Co
st sh
aring
De
ducti
bles
$400
Co
paym
ents
$100
Co
insur
ance
$1
00
Wha
t isn’t
cove
red
Limits
or ex
clusio
ns
$0
The t
otal
Mia w
ould
pay
is
$600
Abou
t the
se C
over
age E
xam
ples
:
This
is no
t a co
st es
timat
or. T
reatm
ents
show
n are
just
exam
ples o
f how
this
plan m
ight c
over
med
ical c
are.
Your
actua
l cos
ts wi
ll be
differ
ent d
epen
ding o
n the
actua
l car
e you
rece
ive, th
e pric
es yo
ur p
rovid
ers c
harg
e, an
d man
y othe
r fac
tors.
Focu
s on t
he co
st sh
aring
am
ounts
(ded
uctib
les, c
opay
ments
and c
oinsu
ranc
e) an
d exc
luded
servi
ces u
nder
the p
lan. U
se th
is inf
orma
tion t
o com
pare
the p
ortio
n of
costs
you m
ight p
ay un
der d
iffere
nt he
alth
plans
. Plea
se no
te the
se co
vera
ge ex
ample
s are
base
d on s
elf-o
nly co
vera
ge.
*Note
: This
plan
has o
ther d
educ
tibles
for s
pecif
ic se
rvice
s inc
luded
in th
is co
vera
ge ex
ample
. See
"Are
ther
e othe
r ded
uctib
les fo
r spe
cific
servi
ces?
” row
abov
e.
.
.
He
alth
care
cove
rage
is im
porta
nt fo
r eve
ryon
e. W
e pro
vide f
ree c
ommu
nicati
on ai
ds an
d ser
vices
for a
nyon
e with
a dis
abilit
y or w
ho ne
eds l
angu
age a
ssist
ance
. W
e do n
ot dis
crimi
nate
on th
e bas
is of
race
, colo
r, na
tiona
l orig
in, se
x, ge
nder
iden
tity, a
ge or
disa
bility
.
To re
ceive
lang
uage
or co
mmun
icatio
n ass
istan
ce fr
ee of
char
ge, p
lease
call u
s at 8
55-71
0-698
4.
If you
belie
ve w
e hav
e fail
ed to
prov
ide a
servi
ce, o
r think
we h
ave d
iscrim
inated
in an
other
way,
conta
ct us
to fil
e a gr
ievan
ce.
Offic
e of C
ivil R
ights
Coor
dinato
r Ph
one:
85
5-66
4-72
70 (v
oicem
ail)
300 E
. Ran
dolph
St.
TTY/
TDD:
85
5-66
1-69
65
35th
Floor
Fa
x:
855-
661-
6960
Ch
icago
, Illin
ois 6
0601
Em
ail:
Ci
vilRi
ghtsC
oord
inator
@hc
sc.ne
t
You m
ay fil
e a ci
vil rig
hts co
mplai
nt wi
th the
U.S
. Dep
artm
ent o
f Hea
lth an
d Hum
an S
ervic
es, O
ffice f
or C
ivil R
ights,
at:
U.S.
Dep
t. of H
ealth
& H
uman
Ser
vices
Ph
one:
800-
368-
1019
20
0 Ind
epen
denc
e Ave
nue S
W
TTY/
TDD:
80
0-53
7-76
97
Room
509F
, HHH
Buil
ding 1
019
Comp
laint
Porta
l: htt
ps://o
crpor
tal.hh
s.gov
/ocr/
porta
l/lobb
y.jsf
Was
hingto
n, DC
202
01
Comp
laint
Form
s: htt
p://w
ww.hh
s.gov
/ocr/o
ffice/f
ile/in
dex.h
tml
1
of 7
Sum
mar
y of B
enef
its an
d Co
vera
ge: W
hat th
is Pl
an C
over
s & W
hat Y
ou P
ay F
or C
over
ed S
ervic
es
Cove
rage
Per
iod:
09/01
/2018
– 08
/31/20
19
Texa
s A&M
Uni
vers
ity S
yste
m: J
Plan
Cove
rage
for:
Indivi
dual
+ Fa
mily
| Plan
Typ
e: P
PO
The S
umm
ary o
f Ben
efits
and
Cove
rage
(SBC
) doc
umen
t will
help
you
choo
se a
healt
h pl
an. T
he S
BC sh
ows y
ou h
ow yo
u an
d th
e plan
wou
ld
shar
e the
cost
for c
over
ed h
ealth
care
serv
ices.
NOTE
: Inf
orm
atio
n ab
out t
he co
st o
f thi
s plan
(call
ed th
e pre
miu
m) w
ill be
pro
vided
sepa
rate
ly.
This
is on
ly a s
umm
ary.
For m
ore i
nform
ation
abou
t you
r cov
erag
e, or
to ge
t a co
py of
the c
omple
te ter
ms of
cove
rage
, call
1-86
6-29
5-12
12 or
visit
ww
w.bc
bstx.
com/
tamus
. For
gene
ral d
efinit
ions o
f com
mon t
erms
, suc
h as a
llowe
d amo
unt,
balan
ce bi
lling,
coins
uran
ce, c
opay
ment,
dedu
ctible
, pro
vider
, or o
ther
unde
rlined
term
s see
the G
lossa
ry. Y
ou ca
n view
the G
lossa
ry at
www.
cms.g
ov/C
CIIO
/Res
ource
s/For
ms-R
epor
ts-an
d-Ot
her-R
esou
rces/D
ownlo
ads/U
G-Gl
ossa
ry-50
8-MM
.pdf o
r call
1-86
6-29
5-12
12 to
requ
est a
copy
.
Impo
rtant
Que
stio
ns
Answ
ers
Why
Thi
s Mat
ters
:
Wha
t is th
e ove
rall
dedu
ctible
?
Braz
os V
alley
Netw
ork:
$400
Indiv
idual
/$1,20
0 Fam
ily
In-Ne
twor
k: $4
00 In
dividu
al / $
1,200
Fam
ily
Out-o
f-Netw
ork:
$800
Indiv
idual
/ $2,4
00 F
amily
Gene
rally
, you
mus
t pay
all o
f the c
osts
from
prov
iders
up to
the d
educ
tible
amou
nt be
fore t
his pl
an be
gins t
o pay
. If yo
u hav
e othe
r fami
ly me
mber
s on t
he
plan,
each
fami
ly me
mber
mus
t mee
t their
own i
ndivi
dual
dedu
ctible
until
the
total
amou
nt of
dedu
ctible
expe
nses
paid
by al
l fami
ly me
mber
s mee
ts the
ov
erall
fami
ly de
ducti
ble.
Are t
here
serv
ices
cove
red b
efore
you
mee
t you
r ded
uctib
le?
Yes.
Servi
ces t
hat c
harg
e a co
pay,
pres
cripti
on dr
ugs,
and
Braz
os V
alley
Netw
ork &
In-N
etwor
k pre
venti
ve ca
re an
d dia
gnos
tic te
sts ar
e cov
ered
befor
e you
mee
t you
r de
ducti
ble.
This
plan c
over
s som
e item
s and
servi
ces e
ven i
f you
have
n’t ye
t met
the
dedu
ctible
amou
nt. B
ut a c
opay
ment
or co
insur
ance
may
apply
. For
exam
ple,
this p
lan co
vers
certa
in pr
even
tive s
ervic
es w
ithou
t cos
t sha
ring a
nd be
fore y
ou
meet
your
dedu
ctible
. See
a lis
t of c
over
ed pr
even
tive s
ervic
es at
ww
w.he
althc
are.g
ov/co
vera
ge/pr
even
tive-
care
-ben
efits/
. Ar
e the
re ot
her
dedu
ctible
s for
spec
ific
serv
ices?
Yes.
Out-o
f-Netw
ork:
$400
non-
emer
genc
y hos
pital
admi
ssion
. $50
Rx d
educ
tible
Braz
os V
alley
, In-,
and
Out-o
f-Netw
ork.
Ther
e are
no ot
her s
pecif
ic de
ducti
bles.
You m
ust p
ay al
l of th
e cos
ts for
thes
e ser
vices
up to
the s
pecif
ic de
ducti
ble
amou
nt be
fore t
his pl
an be
gins t
o pay
for th
ese s
ervic
es.
Wha
t is th
e out
-of-
pock
et lim
it for
this
plan?
Braz
os V
alley
Netw
ork:
$5,00
0 Per
son +
$400
Med
ical
dedu
ctible
/ $10
,000 F
amily
+ $1
,200 M
edica
l ded
uctib
le In-
Netw
ork:
$5,00
0 Per
son +
$400
Med
ical d
educ
tible
/ $1
0,000
Fam
ily +
$1,20
0 Med
ical d
educ
tible
Out-o
f-Netw
ork:
$10,0
00 P
erso
n + $8
00 M
edica
l de
ducti
ble / $
20,00
0 Fam
ily +
$2,40
0 Med
ical d
educ
tible
The o
ut-of-
pock
et lim
it is t
he m
ost y
ou co
uld pa
y in a
year
for c
over
ed se
rvice
s. If y
ou ha
ve ot
her f
amily
mem
bers
in thi
s plan
, they
have
to m
eet th
eir ow
n out-
of-po
cket
limits
until
the ov
erall
fami
ly ou
t-of-p
ocke
t limi
t has
been
met.
Wha
t is no
t inclu
ded i
n th
e out
-of-p
ocke
t lim
it?
Prem
iums,
prea
uthor
izatio
n pen
alties
, bala
nced
-bille
d ch
arge
s, an
d hea
lthca
re th
is pla
n doe
sn’t c
over
. Ev
en th
ough
you p
ay th
ese e
xpen
ses,
they d
on’t c
ount
towar
d the
out-o
f-poc
ket
limit.
Will
you p
ay le
ss if
you
use a
netw
ork
prov
ider?
Ye
s. Se
e www
.bcbs
tx.co
m/tam
us o
r call
1-80
0-52
1-22
27
for a
list o
f netw
ork p
rovid
ers.
You p
ay th
e lea
st if y
ou us
e a pr
ovide
r in B
razo
s Vall
ey N
etwor
k. Yo
u pay
mor
e if y
ou us
e a pr
ovide
r in-n
etwor
k. Yo
u will
pay t
he m
ost if
you u
se an
out-o
f-ne
twor
k pro
vider
, and
you m
ight r
eceiv
e a bi
ll fro
m a p
rovid
er fo
r the
diffe
renc
e be
twee
n the
prov
ider’s
char
ge an
d wha
t you
r plan
pays
(bala
nce b
illing)
. Be
awar
e, yo
ur ne
twor
k pro
vider
migh
t use
an ou
t-of-n
etwor
k pro
vider
for s
ome
servi
ces (
such
as la
b wor
k). C
heck
with
your
prov
ider b
efore
you g
et se
rvice
s. Do
you n
eed a
refer
ral
to se
e a sp
ecial
ist?
No.
You c
an se
e the
spec
ialist
you c
hoos
e with
out a
refer
ral.
\
2
of 7
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see t
he pl
an or
polic
y doc
umen
t at w
ww.bc
bstx.
com/
tamus
.
All c
opay
men
t and
coin
sura
nce c
osts
show
n in t
his ch
art a
re af
ter yo
ur d
educ
tible
has b
een m
et, if
a ded
uctib
le ap
plies
.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
Wha
t You
Will
Pay
Lim
itatio
ns, E
xcep
tions
, &
Othe
r Im
porta
nt In
form
atio
n Br
azos
Vall
ey
Prov
ider
(You
will
pay t
he le
ast)
In-Ne
twor
k Pro
vider
Ou
t-of-N
etwor
k Pr
ovide
r (Y
ou w
ill pa
y the
mos
t)
If yo
u vis
it a
healt
h ca
re
prov
ider
’s of
fice
or cl
inic
Prim
ary c
are v
isit to
trea
t an i
njury
or ill
ness
$5
copa
y/visi
t; de
ducti
ble do
es no
t ap
ply
$20 c
opay
/visit
; de
ducti
ble do
es no
t ap
ply
50%
coins
uran
ce
after
dedu
ctible
No
ne
Spec
ialist
visit
$1
5 cop
ay/vi
sit;
dedu
ctible
does
not
apply
$30 c
opay
/visit
; de
ducti
ble do
es no
t ap
ply
50%
coins
uran
ce
after
dedu
ctible
No
ne
Prev
entiv
e car
e/scre
ening
/ im
muniz
ation
No
Cha
rge;
dedu
ctible
does
not
apply
No C
harg
e;
dedu
ctible
does
not
apply
No
t Cov
ered
You m
ay ha
ve to
pay f
or se
rvice
s tha
t are
n’t pr
even
tive.
Ask y
our
prov
ider if
the s
ervic
es ne
eded
are
prev
entiv
e. Th
en ch
eck w
hat y
our
plan w
ill pa
y for
.
If yo
u ha
ve a
test
Diag
nosti
c tes
t (x-r
ay, b
lood w
ork)
No C
harg
e;
de
ducti
ble do
es no
t ap
ply
No C
harg
e;
de
ducti
ble do
es no
t ap
ply
50%
coins
uran
ce
after
dedu
ctible
Of
fice v
isit c
opay
may
apply
.
Imag
ing (C
T/PE
T sc
ans,
MRIs)
10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
Certa
in Di
agno
stic P
roce
dure
s on
ly. S
ee yo
ur po
licy o
r plan
do
cume
nt for
a lis
t of p
roce
dure
s.
Prea
uthor
izatio
n may
be re
quire
d.
3
of 7
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see t
he pl
an or
polic
y doc
umen
t at w
ww.bc
bstx.
com/
tamus
.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
Wha
t You
Will
Pay
Lim
itatio
ns, E
xcep
tions
, &
Othe
r Im
porta
nt
Info
rmat
ion
Braz
os V
alley
Pro
vider
(Y
ou w
ill pa
y the
leas
t) In-
Netw
ork P
rovid
er
Out-o
f-Netw
ork P
rovid
er
(You
will
pay t
he m
ost)
If yo
u ne
ed d
rugs
to
trea
t you
r illn
ess o
r co
nditi
on
More
infor
matio
n ab
out p
resc
riptio
n dr
ug co
vera
ge is
av
ailab
le at
www.
expr
esss
cripts
.com
Gene
ric dr
ugs
Retai
l: $10
copa
y afte
r $5
0 ded
uctib
le
Ma
il: $2
0 cop
ay a
fter
$50 d
educ
tible
Retai
l: $10
copa
y aft
er $5
0 ded
uctib
le
Ma
il: $2
0 cop
ay a
fter
$50 d
educ
tible
Total
cost
of pr
escri
ption
at
the tim
e of s
ervic
e. 75
% of
all
owab
le ch
arge
s are
re
imbu
rsed a
fter d
educ
tible
and a
pplic
able
copa
ymen
t.
Retai
l: one
copa
y per
30
day s
upply
Mail:
two c
opay
s up t
o 90
day s
upply
Pr
eferre
d bra
nd dr
ugs
Retai
l: $35
copa
y afte
r $5
0 ded
uctib
le
Ma
il: $7
0 cop
ay af
ter
$50 d
educ
tible
Retai
l: $35
copa
y aft
er $5
0 ded
uctib
le
Ma
il: $7
0 cop
ay af
ter
$50 d
educ
tible
Total
cost
of pr
escri
ption
at
the tim
e of s
ervic
e. 75
% of
all
owab
le ch
arge
s are
re
imbu
rsed a
fter d
educ
tible
and a
pplic
able
copa
ymen
t.
Non-
prefe
rred b
rand
drug
s Re
tail: $
60 co
pay a
fter
$50 d
educ
tible
Mail:
$120
copa
y afte
r $5
0 ded
uctib
le
Retai
l: $60
copa
y aft
er $5
0 ded
uctib
le
Ma
il: $1
20 co
pay a
fter
$50 d
educ
tible
Total
cost
of pr
escri
ption
at
the tim
e of s
ervic
e. 75
% of
all
owab
le ch
arge
s are
re
imbu
rsed a
fter d
educ
tible
and a
pplic
able
copa
ymen
t.
Spec
ialty
drug
s
Gene
ric $1
0 cop
ay
Prefe
rred $
35 co
pay
Non-
prefe
rred $
60
copa
y afte
r $50
de
ducti
ble
Gene
ric $1
0 cop
ay
Prefe
rred $
35 co
pay
Non-
prefe
rred $
60
copa
y afte
r $50
de
ducti
ble
Total
cost
of pr
escri
ption
at
the tim
e of s
ervic
e. 75
% of
all
owab
le ch
arge
s are
re
imbu
rsed a
fter d
educ
tible
and a
pplic
able
copa
ymen
t.
Begin
ning w
ith se
cond
fill
spec
ialty
medic
ation
mus
t be
filled
thro
ugh S
pecia
lty
Phar
macy
: one
copa
ymen
t pe
r 30 d
ay su
pply
If yo
u ha
ve
outp
atien
t sur
gery
Facil
ity fe
e (e.g
., amb
ulator
y su
rger
y cen
ter)
10%
coins
uran
ce
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
None
Phys
ician
/surg
eon f
ees
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
50%
coins
uran
ce
after
dedu
ctible
No
ne
If yo
u ne
ed
imm
ediat
e m
edica
l atte
ntio
n
Emer
genc
y roo
m ca
re
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
No
ne
Emer
genc
y med
ical tr
ansp
ortat
ion
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
No
ne
Urge
nt ca
re
$5/$1
5 cop
ay/vi
sit;
dedu
ctible
does
not
apply
$20/$
30 co
pay/v
isit;
dedu
ctible
does
not
apply
50
% co
insur
ance
aft
er de
ducti
ble
None
4
of 7
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see t
he pl
an or
polic
y doc
umen
t at w
ww.bc
bstx.
com/
tamus
.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
W
hat Y
ou W
ill Pa
y Li
mita
tions
, Exc
eptio
ns, &
Ot
her I
mpo
rtant
Info
rmat
ion
Braz
os V
alley
Pro
vider
(Y
ou w
ill pa
y the
leas
t) In-
Netw
ork P
rovid
er
Out-o
f-Netw
ork P
rovid
er
(You
will
pay t
he m
ost)
If yo
u ha
ve a
hosp
ital s
tay
Facil
ity fe
e (e.g
., hos
pital
room
) 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50%
coins
uran
ce af
ter
dedu
ctible
plus
$400
per
occu
rrenc
e ded
uctib
le for
no
n-em
erge
ncy a
dmiss
ion
All n
on-e
merg
ency
servi
ces m
ust
be pr
eauth
orize
d; $5
00 pe
nalty
if no
t pre
autho
rized
In-N
etwor
k or
Out-o
f-Netw
ork.
Phys
ician
/surg
eon f
ees
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
50%
coins
uran
ce
after
dedu
ctible
No
ne
If yo
u ne
ed
men
tal h
ealth
, be
havio
ral
healt
h, o
r su
bsta
nce a
buse
se
rvice
s
Outpa
tient
servi
ces
$5 co
pay/o
ffice v
isit;
dedu
ctible
does
not
apply
10
% co
insur
ance
for
other
outpa
tient
servi
ces
$20 c
opay
/offic
e vis
it; de
ducti
ble
does
not a
pply
20%
coins
uran
ce
for ot
her o
utpati
ent
servi
ces
50%
coins
uran
ce
after
dedu
ctible
Ce
rtain
servi
ces m
ust b
e pr
eauth
orize
d; re
fer to
plan
do
cume
nt.
Inpati
ent s
ervic
es
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
50%
coins
uran
ce af
ter
dedu
ctible
plus
$400
per
occu
rrenc
e ded
uctib
le for
no
n-em
erge
ncy a
dmiss
ion
All n
on-e
merg
ency
servi
ces m
ust
be pr
eauth
orize
d; $5
00 pe
nalty
if no
t pre
autho
rized
In-N
etwor
k or
Out-o
f-Netw
ork.
If yo
u ar
e pr
egna
nt
Offic
e visi
ts $5
/$15 c
opay
/initia
l vis
it; de
ducti
ble do
es
not a
pply
$20/$
30 co
pay/i
nitial
vis
it; de
ducti
ble
does
not a
pply
50%
coins
uran
ce
after
dedu
ctible
Spec
ialist
has h
igher
copa
y. No
Ch
arge
after
initia
l cop
ay. F
or
phys
ician
servi
ces o
nly.
Co
st sh
aring
does
not a
pply
for
prev
entiv
e ser
vices
. Dep
endin
g on
the t
ype o
f ser
vices
, a
copa
ymen
t, coin
sura
nce,
or
dedu
ctible
may
apply
. Mate
rnity
ca
re m
ay in
clude
tests
and
servi
ces d
escri
bed e
lsewh
ere i
n the
SBC
(i.e.
ultra
soun
d).
Child
birth/
deliv
ery p
rofes
siona
l se
rvice
s 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
Child
birth/
deliv
ery f
acilit
y se
rvice
s 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50%
coins
uran
ce af
ter
dedu
ctible
plus
$400
per
occu
rrenc
e ded
uctib
le for
no
n-em
erge
ncy a
dmiss
ion
All n
on-e
merg
ency
servi
ces m
ust
be pr
eauth
orize
d; $5
00 pe
nalty
if no
t pre
autho
rized
In-N
etwor
k or
Out-o
f-Netw
ork.
5
of 7
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see t
he pl
an or
polic
y doc
umen
t at w
ww.bc
bstx.
com/
tamus
.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
W
hat Y
ou W
ill Pa
y Li
mita
tions
, Exc
eptio
ns, &
Ot
her I
mpo
rtant
Info
rmat
ion
Braz
os V
alley
Pro
vider
(Y
ou w
ill pa
y the
leas
t) In-
Netw
ork P
rovid
er
Out-o
f-Netw
ork P
rovid
er
(You
will
pay t
he m
ost)
If yo
u ne
ed
help
re
cove
ring
or
have
oth
er
spec
ial h
ealth
ne
eds
Home
healt
h car
e 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
All se
rvice
s mus
t be p
reauth
orize
d. Lim
ited t
o 60 v
isits
per p
lan ye
ar.
Reha
bilita
tion s
ervic
es
$15 c
opay
/visit
; de
ducti
ble do
es no
t app
ly $3
0 cop
ay/vi
sit;
dedu
ctible
does
not a
pply
50%
coins
uran
ce
after
dedu
ctible
No
ne
Habil
itatio
n ser
vices
$1
5 cop
ay/vi
sit;
dedu
ctible
does
not a
pply
$30 c
opay
/visit
; de
ducti
ble do
es no
t app
ly 50
% co
insur
ance
aft
er de
ducti
ble
None
Skille
d nur
sing c
are
10%
coins
uran
ce
after
dedu
ctible
20
% co
insur
ance
aft
er de
ducti
ble
50%
coins
uran
ce
after
dedu
ctible
All
servi
ces m
ust b
e prea
uthori
zed.
Limite
d to 6
0 day
s per
plan y
ear.
Dura
ble m
edica
l equ
ipmen
t 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
None
Hosp
ice se
rvice
s 10
% co
insur
ance
aft
er de
ducti
ble
20%
coins
uran
ce
after
dedu
ctible
50
% co
insur
ance
aft
er de
ducti
ble
All se
rvice
s mus
t be p
reauth
orize
d.
No
plan
max
imum
s.
If yo
ur ch
ild
need
s den
tal
or ey
e car
e
Child
ren’s
eye e
xam
$15 c
opay
/visit
;
dedu
ctible
does
not a
pply
$30 c
opay
/visit
; de
ducti
ble do
es no
t app
ly 50
% co
insur
ance
aft
er de
ducti
ble
None
Child
ren’s
glas
ses
Not C
over
ed
Not C
over
ed
Not C
over
ed
None
Child
ren’s
denta
l che
ck-u
p No
t Cov
ered
No
t Cov
ered
No
t Cov
ered
No
ne
Exclu
ded
serv
ices &
Oth
er C
over
ed S
ervic
es:
Serv
ices Y
our P
lan G
ener
ally D
oes N
OT C
over
(Che
ck yo
ur p
olicy
or p
lan d
ocum
ent f
or m
ore i
nfor
mat
ion
and
a list
of a
ny o
ther
exclu
ded
serv
ices.)
•
Cosm
etic s
urge
ry
• De
ntal c
are (
Adult
) •
• Inf
ertili
ty tre
atmen
t •
Long
-term
care
•
Routi
ne fo
ot ca
re (c
over
ed on
ly wi
th dia
gnos
is of
diabe
tes)
• W
eight
loss p
rogr
ams (
exce
pt Na
turall
y Slim
prog
ram)
Ot
her C
over
ed S
ervic
es (L
imita
tions
may
appl
y to
thes
e ser
vices
. Thi
s isn
’t a c
ompl
ete l
ist. P
lease
see y
our p
lan d
ocum
ent.)
•
Acup
unctu
re (li
mitat
ions m
ay ap
ply)
• Ba
riatric
surg
ery (
limita
tions
may
apply
) •
Chiro
prac
tic ca
re (li
mitat
ions m
ay ap
ply)
• He
aring
aids
•
Non-
emer
genc
y car
e whe
n tra
velin
g outs
ide th
e U.S
. •
Priva
te-du
ty nu
rsing
•
Routi
ne ey
e car
e (Ad
ult V
ision
Scre
ening
)
6
of 7
Your
Rig
hts t
o Co
ntin
ue C
over
age:
The
re ar
e age
ncies
that
can h
elp if
you w
ant to
conti
nue y
our c
over
age a
fter it
ends
. The
conta
ct inf
orma
tion f
or th
ose
agen
cies i
s: the
plan
at 1-
866-
295-
1212
, U.S
. Dep
artm
ent o
f Lab
or’s
Emplo
yee B
enefi
ts Se
curity
Adm
inistr
ation
at 1
-866
-444
-EBS
A (3
272)
or
www.
dol.g
ov/eb
sa/he
althr
eform
, or D
epar
tmen
t of H
ealth
and H
uman
Ser
vices
, Cen
ter fo
r Con
sume
r Info
rmati
on an
d Ins
uran
ce O
versi
ght, a
t 1-8
77-2
67-2
323
x615
65 or
www
.cciio
.cms.g
ov. O
ther c
over
age o
ption
s may
be av
ailab
le to
you t
oo, in
cludin
g buy
ing in
dividu
al ins
uran
ce co
vera
ge th
roug
h the
Hea
lth In
sura
nce
Marke
tplac
e. Fo
r mor
e info
rmati
on ab
out th
e Ma
rketpl
ace,
visit w
ww.H
ealth
Care
.gov o
r call
1-80
0-31
8-25
96.
Your
Grie
vanc
e and
App
eals
Righ
ts: T
here
are a
genc
ies th
at ca
n help
if yo
u hav
e a co
mplai
nt ag
ainst
your
plan
for a
denia
l of a
claim
. This
comp
laint
is ca
lled a
gr
ievan
ce or
appe
al. F
or m
ore i
nform
ation
abou
t you
r righ
ts, lo
ok at
the e
xplan
ation
of be
nefits
you w
ill re
ceive
for t
hat m
edica
l clai
m. Y
our p
lan do
cume
nts al
so
prov
ide co
mplet
e info
rmati
on to
subm
it a cl
aim, a
ppea
l, or a
griev
ance
for a
ny re
ason
to yo
ur p
lan. F
or m
ore i
nform
ation
abou
t you
r righ
ts, th
is no
tice,
or as
sistan
ce,
conta
ct: B
lue C
ross
and B
lue S
hield
of Te
xas a
t 1-8
66-2
95-1
212 o
r visi
t www
.bcbs
tx.co
m, or
conta
ct the
U.S
. Dep
artm
ent o
f Lab
or's
Emplo
yee B
enefi
ts Se
curity
Ad
minis
tratio
n at 1
-866
-444
-EBS
A (3
272)
or vi
sit w
ww.do
l.gov
/ebsa
/healt
hrefo
rm. A
dditio
nally
, a co
nsum
er as
sistan
ce pr
ogra
m ca
n help
you f
ile yo
ur a
ppea
l. Co
ntact
the T
exas
Dep
artm
ent o
f Insu
ranc
e's C
onsu
mer H
ealth
Ass
istan
ce P
rogr
am at
1-8
00-2
52-3
439 o
r visi
t www
.texa
shea
lthop
tions
.com.
Do
es th
is pl
an p
rovid
e Min
imum
Ess
entia
l Cov
erag
e? Y
es
If you
don’t
have
Mini
mum
Esse
ntial
Cove
rage
for a
mon
th, yo
u’ll h
ave t
o ma
ke a
paym
ent w
hen y
ou fil
e you
r tax
retur
n un
less y
ou qu
alify
for an
exem
ption
from
the
requ
ireme
nt tha
t you
have
healt
h cov
erag
e for
that
month
. Do
es th
is pl
an m
eet t
he M
inim
um V
alue S
tand
ards
? Ye
s If y
our p
lan do
esn’t
mee
t the M
inimu
m Va
lue S
tanda
rds,
you m
ay be
eligi
ble fo
r a pr
emium
tax c
redit
to he
lp yo
u pay
for a
plan
thro
ugh t
he M
arke
tplac
e. La
ngua
ge A
cces
s Ser
vices
: Sp
anish
(Esp
añol)
: Par
a obte
ner a
sisten
cia en
Esp
añol,
llam
e al 1
-866
-295
-121
2. Ta
galog
(Tag
alog)
: Kun
g kail
anga
n niny
o ang
tulon
g sa T
agalo
g tum
awag
sa 1-
866-
295-
1212
. Ch
inese
(中文
): 如果需要中文的帮助，请拨打这个号码
1-86
6-29
5-12
12.
Nava
jo (D
ine):
Dine
k'ehg
o shik
a at'o
hwol
ninisi
ngo,
kwiiji
go ho
lne' 1
-866
-295
-121
2.
––––
––––
––––
––––
––––
––To
see
exam
ples o
f how
this
plan
migh
t cov
er co
sts fo
r a sa
mple
med
ical s
ituat
ion, s
ee th
e ne
xt se
ction
. –––
––––
––––
––––
––––
–––
7
of 7
The p
lan w
ould
be re
spon
sible
for th
e othe
r cos
ts of
these
EXA
MPLE
cove
red s
ervic
es.
Peg
is Ha
ving
a Bab
y (9
mon
ths of
in-n
etwor
k pre
-nata
l car
e and
a ho
spita
l deli
very)
Mia’s
Sim
ple F
ract
ure
(in-n
etwor
k eme
rgen
cy ro
om vi
sit an
d foll
ow
up ca
re)
Mana
ging
Joe’s
type
2 Di
abet
es
(a ye
ar of
routi
ne in
-netw
ork c
are o
f a w
ell-
contr
olled
cond
ition)
T
he p
lan’s
over
all d
educ
tible
$4
00
S
pecia
list c
opay
men
ts
$15
H
ospi
tal (
facil
ity) c
oins
uran
ce
10%
Oth
er co
insu
ranc
e 10
%
This
EXAM
PLE
even
t inc
lude
s ser
vices
like:
Sp
ecial
ist of
fice v
isits
(pre
nata
l car
e)
Child
birth/
Deliv
ery P
rofes
siona
l Ser
vices
Ch
ildbir
th/De
liver
y Fac
ility S
ervic
es
Diag
nosti
c tes
ts (u
ltras
ound
s and
bloo
d wo
rk)
Spec
ialist
visit
(ane
sthes
ia)
Tota
l Exa
mpl
e Cos
t $1
2,800
In
this
exam
ple,
Peg
woul
d pa
y:
Cost
shar
ing
Dedu
ctible
s $4
00
Copa
ymen
ts $5
0 Co
insur
ance
$1
,100
Wha
t isn’t
cove
red
Limits
or ex
clusio
ns
$60
The t
otal
Peg
woul
d pa
y is
$1,61
0
T
he p
lan’s
over
all d
educ
tible
$4
00
S
pecia
list c
opay
men
ts
$15
H
ospi
tal (
facil
ity) c
oins
uran
ce
10%
Oth
er co
insu
ranc
e 10
%
This
EXAM
PLE
even
t inc
lude
s ser
vices
like:
Pr
imar
y car
e phy
sician
offic
e visi
ts (in
cludin
g dis
ease
edu
catio
n)
Diag
nosti
c tes
ts (b
lood
work
) Pr
escri
ption
drug
s Du
rable
med
ical e
quipm
ent (
gluco
se m
eter
) To
tal E
xam
ple C
ost
$7,40
0 In
this
exam
ple,
Joe w
ould
pay
: Co
st sh
aring
De
ducti
bles*
$4
50
Copa
ymen
ts $8
00
Coins
uran
ce
$100
W
hat is
n’t co
vere
d Lim
its or
exclu
sions
$6
0 Th
e tot
al Jo
e wou
ld p
ay is
$1
,410
T
he p
lan’s
over
all d
educ
tible
$400
Spe
cialis
t cop
aym
ents
$1
5
Hos
pita
l (fa
cility
) coi
nsur
ance
1
0%
O
ther
coin
sura
nce
10%
Th
is EX
AMPL
E ev
ent i
nclu
des s
ervic
es lik
e:
Emer
genc
y roo
m ca
re (in
cludin
g m
edica
l su
pplie
s) Di
agno
stic t
est (
x-ra
y)
Dura
ble m
edica
l equ
ipmen
t (cru
tches
) Re
habil
itatio
n ser
vices
(phy
sical
ther
apy)
To
tal E
xam
ple C
ost
$1,90
0 In
this
exam
ple,
Mia w
ould
pay
: Co
st sh
aring
De
ducti
bles
$400
Co
paym
ents
$100
Co
insur
ance
$1
00
Wha
t isn’t
cove
red
Limits
or ex
clusio
ns
$0
The t
otal
Mia w
ould
pay
is
$600
Abou
t the
se C
over
age E
xam
ples
:
This
is no
t a co
st es
timat
or. T
reatm
ents
show
n are
just
exam
ples o
f how
this
plan m
ight c
over
med
ical c
are.
Your
actua
l cos
ts wi
ll be
differ
ent d
epen
ding o
n the
actua
l car
e you
rece
ive, th
e pric
es yo
ur p
rovid
ers c
harg
e, an
d man
y othe
r fac
tors.
Focu
s on t
he co
st sh
aring
am
ounts
(ded
uctib
les, c
opay
ments
and c
oinsu
ranc
e) an
d exc
luded
servi
ces u
nder
the p
lan. U
se th
is inf
orma
tion t
o com
pare
the p
ortio
n of
costs
you m
ight p
ay un
der d
iffere
nt he
alth
plans
. Plea
se no
te the
se co
vera
ge ex
ample
s are
base
d on s
elf-o
nly co
vera
ge.
*Note
: This
plan
has o
ther d
educ
tibles
for s
pecif
ic se
rvice
s inc
luded
in th
is co
vera
ge ex
ample
. See
"Are
ther
e othe
r ded
uctib
les fo
r spe
cific
servi
ces?
” row
abov
e.
.
.
He
alth
care
cove
rage
is im
porta
nt fo
r eve
ryon
e. W
e pro
vide f
ree c
ommu
nicati
on ai
ds an
d ser
vices
for a
nyon
e with
a dis
abilit
y or w
ho ne
eds l
angu
age a
ssist
ance
. W
e do n
ot dis
crimi
nate
on th
e bas
is of
race
, colo
r, na
tiona
l orig
in, se
x, ge
nder
iden
tity, a
ge or
disa
bility
.
To re
ceive
lang
uage
or co
mmun
icatio
n ass
istan
ce fr
ee of
char
ge, p
lease
call u
s at 8
55-71
0-698
4.
If you
belie
ve w
e hav
e fail
ed to
prov
ide a
servi
ce, o
r think
we h
ave d
iscrim
inated
in an
other
way,
conta
ct us
to fil
e a gr
ievan
ce.
Offic
e of C
ivil R
ights
Coor
dinato
r Ph
one:
85
5-66
4-72
70 (v
oicem
ail)
300 E
. Ran
dolph
St.
TTY/
TDD:
85
5-66
1-69
65
35th
Floor
Fa
x:
855-
661-
6960
Ch
icago
, Illin
ois 6
0601
Em
ail:
Ci
vilRi
ghtsC
oord
inator
@hc
sc.ne
t
You m
ay fil
e a ci
vil rig
hts co
mplai
nt wi
th the
U.S
. Dep
artm
ent o
f Hea
lth a
nd H
uman
Ser
vices
, Offic
e for
Civi
l Righ
ts, at
: U.
S. D
ept. o
f Hea
lth &
Hum
an S
ervic
es
Phon
e: 80
0-36
8-10
19
200 I
ndep
ende
nce A
venu
e SW
TT
Y/TD
D:
800-
537-
7697
Ro
om 50
9F, H
HH B
uildin
g 101
9 Co
mplai
nt Po
rtal:
https
://ocrp
ortal
.hhs.g
ov/oc
r/por
tal/lo
bby.j
sf W
ashin
gton,
DC 2
0201
Co
mplai
nt Fo
rms:
http:/
/www
.hhs.g
ov/oc
r/offic
e/file
/inde
x.htm
l
29 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
LifeBasic Life/Basic AD&D
Coverage for you: Child Coverage:
You are automatically covered if you are enrolled in an A&M System health plan.$7,500 in life insurance and $5,000 in AD&D coverage $5,000 in life insurance on each eligible dependent child.
Alternate Basic Life/Basic AD&D
Coverage for you:
Child Coverage:
If you are not enrolled in System health coverage, but certify that you have other health coverage, you can pay for Alternate Basic Life using the employer contribution. If you select this coverage, you cannot enroll in Optional Life.$50,000 or the amount of optional life you had immediately before enrolling in this plan, whichever is less, as well as $5,000 in Basic AD&D coverage$5,000 in life insurance on each eligible dependent child.
Optional Life Maximum of $100,000 if younger than 70. Coverage will automatically be reduced to $60,000 at age 70 and $30,000 at age 80.
Dependent Life Plan A Spouse coverage:
Child Coverage:
You can enroll your dependents if you have Optional Life coverage. You pay for the coverage yourself. 25,000 or $50,000, if retiree is younger than 70. Maximum spouse coverage is $30,000 for retirees ages 70–79 and $15,000 if retiree is age 80 or older. $10,000 per child.
Dependent Life Plan B Spouse coverage: Child Coverage:
5,000 in life and $5,000 in AD&D coverage; if spouse is enrolled. 5,000 in life insurance on each eligible enrolled dependent child.
Dependent Life Plan C Spouse coverage: Child Coverage:
You can enroll your dependents if you have Alternate Basic Life coverage. You pay for the coverage yourself. 50% of your Alternate Basic Life coverage amount, if spouse is enrolled. 10% of your Alternate Basic Life coverage amount on each enrolled child.
• If you had coverage prior to 09-01-09, your dependent coverage amount(s) may be greater than the above maximums.• You must provide evidence of insurability to enroll in or increase Life insurance coverage for you or your spouse. A medical
questionnaire is available from your Human Resources office.
AD&DAccidental Death & Dismemberment provides benefits for an accidental injury that results in the death or dismemberment of a covered person. You can choose up to $200,000 age <70 and up to $60,000 if age >70 . You may choose retiree-only or family coverage.Vision
Network benefit Non-Network benefitEye exam (one/person/per plan year)Materials
Contact lenses (once every plan year in place of frame and lens benefits)Refractive eye surgery
100% after $10 copayment100% after $15 copayment for: Frames and lenses, one standard pair/plan year.up to $150 allowance 15% off reasonable and customary cost, or 5% off promotional price.
Up to $50. Copay does not apply.Lenses: $50 to $100, depending on lens type. Frames: Up to $90. (Copay doesn’t apply).up to $150 allowance
N/A
Dental• You must live in the Dental HMO (DHMO) service area to select the DHMO. If you do not have a DHMO Dentist in your zip code
area, but are willing to travel, contact your HR office.• The DHMO requires you to select a primary dentist to use for authorization of all dental services.• You cannot change plans during the plan year unless you move out of the DHMO service area, and• You cannot add or drop coverage for yourself or any dependents during the plan year unless you have a certain Life Event.
A&M Dental PPO DeltaCare USA Dental HMO
DeductibleMaximum benefit
Your cost for preventive care
Your cost for basic care
Your cost for major restorative care
Your cost for orthodontic care
$75/person/plan year; $225 family/plan yearRegular: $1,500/person/plan year; Orthodontia: $1,500/person/lifetime$0 (if you use a network provider). The plan covers three regular or periodontal cleanings per plan year at 100% up to maximum allowable charges. Deductible does not apply.You pay the deductible plus 20% of the maximum allowable charges for fillings, root canals, extractions and periodontics, up to the $1,500 maximum annual benefitAfter deductible, 50% of the maximum allowable charges for crowns, dentures and bridges, up to annual maximum.After deductible, 50% up to maximum benefit.
NoneNo maximum
Comprehensive oral exam: $0;Cleaning (once each six months): $5;Panoramic X-rays (once every three years): $0You pay a pre-set fee, for example: Amalgam fillings: $8-$22; Anterior root canal, $155
You pay a pre-set fee, for example: Crown; porcelain/ceramic: $395; Complete denture; maxillary: $385You pay a pre-set fee, for example:Orthodontic treatment plan and records: $200 Comprehensive treatment, adults: $2,100
Prem
ium
s
Sept
embe
r 1, 2
018
Hea
lth r
ates
incl
ude
the
$30
wel
lnes
s pr
emiu
m fo
r yo
u an
d yo
ur s
pous
e. O
nly
the
A&
M C
are
Pla
n is
elig
ible
for
the
wel
lnes
s pr
emiu
m. I
f you
hav
e m
et y
our
wel
lnes
s in
cent
ive,
you
will
see
a $
30 c
redi
t in
Wor
kday
that
will
red
uce
this
pre
miu
m. P
rem
ium
s in
crea
se b
y $3
0/m
onth
if y
ou o
r yo
ur s
pous
e is
a to
bacc
o us
er:
H
ealth
Em
ploy
ee O
nly
Em
ploy
ee &
Spo
use
Em
ploy
ee &
Chi
ld(r
en)
Em
ploy
ee &
Fam
ily
Tota
l Cos
t Y
our
Cos
t To
tal C
ost
You
r C
ost
Tota
l Cos
t Y
our
Cos
t To
tal C
ost
You
r C
ost
A&
M C
are
Mon
thly
$6
23.7
7 $3
0.00
$1
,215
.88
$341
.05
$1,0
14.2
7 $2
25.2
5 $1
,444
.71
$455
.47
Bi-W
eekl
y $6
23.7
7 $1
5.00
$1
,215
.88
$170
.53
$1,0
14.2
7 $1
12.6
3 $1
,444
.71
$227
.74
J Pla
n M
onth
ly
$593
.77
$0.0
0 $1
,155
.88
$281
.05
$984
.27
$195
.25
$1,3
84.7
1 $3
95.4
7 B
i Wee
kly
$593
.77
$0.0
0 $1
,155
.88
$140
.53
$984
.27
$97.
63
$1,3
84.7
1 $1
97.7
4 Pa
rt-T
ime
Em
ploy
ees
(wor
k a
20-2
9 ho
ur w
eek)
E
mpl
oyee
Onl
y E
mpl
oyee
& S
pous
e E
mpl
oyee
& C
hild
(ren
) E
mpl
oyee
& F
amily
To
tal C
ost
You
r C
ost
Tota
l Cos
t Y
our
Cos
t To
tal C
ost
You
r C
ost
Tota
l Cos
t Y
our
Cos
t A
&M
C
are
Mon
thly
$6
23.7
7 $3
30.1
8 $1
,215
.88
$781
.76
$1,0
14.2
7 $6
23.0
5 $1
,444
.71
$953
.38
Bi-W
eekl
y $6
23.7
7 $1
65.0
9 $1
,215
.88
$390
.88
$1,0
14.2
7 $3
11.5
3 $1
,444
.71
$476
.69
J Pla
n M
onth
ly
$593
.77
$300
.18
$1,1
55.8
8 $7
21.7
6 $9
84.2
7 $5
93.0
5 $1
,384
.71
$893
.38
Bi-W
eekl
y $5
93.7
7 $1
50.0
9 $1
,155
.88
$360
.88
$984
.27
$296
.53
$1,3
84.7
1 $4
46.6
9 G
radu
ate
Plan
M
onth
ly
$208
.00
$37.
00
$416
.00
$74.
00
$549
.00
$157
.78
$757
.00
$265
.67
Bi W
eekl
y $2
08.0
0 $1
8.50
$4
16.0
0 $3
7.00
$5
49.0
0 $7
8.89
$7
57.0
0 $1
32.8
4
Den
tal
E
mpl
oyee
Onl
y E
mpl
oyee
& S
pous
e E
mpl
oyee
& C
hild
(ren
) E
mpl
oyee
& F
amily
A
&M
Den
tal P
PO
Mon
thly
$2
9.41
$5
8.82
$6
1.76
$9
4.11
B
i-Wee
kly
$14.
71
$29.
41
$30.
88
$47.
06
Del
taCa
re U
SA
Den
tal H
MO
M
onth
ly
$19.
11
$33.
98
$34.
25
$53.
21
Bi-W
eekl
y $9
.56
$16.
99
$17.
13
$26.
61
V
ision
E
mpl
oyee
Onl
y E
mpl
oyee
& S
pous
e E
mpl
oyee
& C
hild
(ren
) E
mpl
oyee
& F
amily
M
onth
ly
$7.0
0 $1
4.88
$1
1.50
$2
0.50
B
i-Wee
kly
$3.5
0 $7
.44
$5.7
5 $1
0.25
AD
&D
R
ate
per
$10,
000:
Em
ploy
ee O
nly
Em
ploy
ee a
nd F
amily
M
onth
ly
$.14
$.
24
Bi-W
eekl
y $.
07
$.12
Long
-Ter
m
Disa
bilit
y R
ate
per
$100
of
mon
thly
sal
ary:
N
on-T
obac
co R
ate
Toba
cco
Rat
e M
onth
ly
$.17
8 $.
230
Bi-W
eekl
y $.
089
$.11
5
Fl
exib
le S
pend
ing
Acc
ount
M
axim
um y
ou c
an d
educ
t fro
m y
our
pay:
Hea
lth C
are
Spen
ding
Acc
ount
- $2
,650
D
epen
dent
Day
care
Spe
ndin
g A
ccou
nt -
$5,0
00
Basic
Life
Th
e pre
miu
m fo
r thi
s pla
n is
usu
ally
pai
d by
the e
mpl
oyer
cont
ribut
ion.
Bas
ic L
ife: $
6.59
A
ltern
ate
Bas
ic L
ife: $
.878
per
$1,
000
of c
over
age
O
ptio
nal L
ife
Y
our a
ge o
n Se
ptem
ber 1
will
be
the
age
used
to c
alcu
late
you
r pre
miu
ms f
or th
e re
st o
f the
fisc
al y
ear.
If yo
u ar
e a
bi-w
eekl
y em
ploy
ee, t
he li
fe ra
tes a
re d
ivid
ed in
hal
f per
mon
th. M
onth
ly ra
te p
er $
1,00
0:
Age
=
Und
er 2
5 25
-29
30-3
4 35
-39
40-4
4 45
-49
50-5
4 55
-59
60-6
4 65
-69
70-7
4 75
+ N
on-T
obac
co R
ate
Mon
thly
$.
05
$.05
$.
05
$.06
$.
07
$.12
$.
20
$.36
$.
56
$.76
$1
.43
$2.0
0 To
bacc
o R
ate
Mon
thly
$.
10
$.10
$.
10
$.12
$.
14
$.24
$.
40
$.72
$1
.12
$1.5
2 $2
.86
$4.0
0
D
epen
dent
Li
fe
Pl
an A
: Spo
use
Age
-bas
ed ra
te p
er $
1,00
0 of
cov
erag
e; C
hild
: $.0
6 pe
r $1,
000
of c
over
age
Plan
B: $
1.37
/mon
th (f
lat r
ate)
Pl
an C
: ½ A
ltern
ate
Bas
ic L
ife p
rem
ium
; 1/1
0 if
no sp
ouse
is c
over
ed
Age
=
Und
er 2
5 25
-29
30-3
4 35
-39
40-4
4 45
-49
50-5
4 55
-59
60-6
4 65
-69
70-7
4 75
+ N
on-T
obac
co R
ate
Mon
thly
$.
05
$.06
$.
08
$.09
$.
10
$.15
$.
23
$.43
$.
66
$1.2
7 $2
.06
$2.0
6 To
bacc
o R
ate
Mon
thly
$.
060
$.07
2 $.
096
$.10
8 $.
120
$.18
0 $.
276
$.51
6 $.
792
$1.5
24
$2.4
72
$2.4
72
Prem
ium
s – 9
Mon
th F
ull-T
ime
Empl
oyee
Se
ptem
ber 1
, 201
8 F
or 9
-mon
th, f
ull-
time
mon
thly
pai
d po
sitio
ns, p
rem
ium
s ar
e pr
orat
ed s
o th
at y
ou p
ay fo
r 12
mon
ths
of p
rem
ium
s ov
er 9
mon
ths.
Thi
s m
eans
that
you
pay
for
12
mon
ths
of p
rem
ium
s by
May
31.
You
do
not h
ave
to p
ay p
rem
ium
s du
ring
the
sum
mer
and
you
will
hav
e co
vera
ge, u
nles
s yo
u ar
e te
rmin
atin
g em
ploy
men
t. In
th
is c
ase,
you
will
rec
eive
a r
efun
d fo
r th
e su
mm
er m
onth
s. T
obac
co u
ser
and
wel
lnes
s ch
arge
s, if
app
licab
le, a
re $
40/m
onth
, sin
ce th
ey a
re p
rora
ted.
If y
ou h
ave
a w
elln
ess
cred
it, th
at is
pro
rate
d as
wel
l. H
ealth
rat
es in
clud
e a
pror
ated
$30
wel
lnes
s pr
emiu
m fo
r bo
th y
ou a
nd y
our
spou
se. O
nly
the
A&
M C
are
Pla
n is
el
igib
le fo
r th
e w
elln
ess
prem
ium
. If y
ou h
ave
met
you
r w
elln
ess
ince
ntiv
e, y
ou w
ill s
ee a
pro
rate
d $3
0 cr
edit
in W
orkd
ay th
at w
ill r
educ
e th
is p
rem
ium
. Pre
miu
ms
incr
ease
by
$40
if yo
u or
you
r sp
ouse
is a
toba
cco
user
:
H
ealth
Em
ploy
ee O
nly
Em
ploy
ee &
Spo
use
Em
ploy
ee &
Chi
ld(r
en)
Em
ploy
ee &
Fam
ily
Tota
l Cos
t Y
our
Cos
t To
tal C
ost
You
r C
ost
Tota
l Cos
t Y
our
Cos
t To
tal C
ost
You
r C
ost
A&
M C
are
9-M
onth
s $8
31.6
9 $4
0.00
$1
,621
.17
$454
.73
$1,3
52.3
6 $3
00.3
3 $1
,926
.28
$607
.29
J Pla
n 9-
Mon
ths
$791
.69
$40.
00
$1,6
21.1
7 $4
54.7
3 $1
,352
.36
$300
.33
$1,3
52.3
6 $6
07.2
9 D
enta
l
Em
ploy
ee O
nly
Em
ploy
ee &
Spo
use
Em
ploy
ee &
Chi
ld(r
en)
Em
ploy
ee &
Fam
ily
A&
M D
enta
l PPO
9-
Mon
ths
$39.
21
$78.
43
$82.
35
$125
.48
Del
taCa
re U
SA
Den
tal H
MO
9-
Mon
ths
$25.
48
$45.
31
$45.
67
$70.
95
Den
tal
E
mpl
oyee
Onl
y E
mpl
oyee
& S
pous
e E
mpl
oyee
& C
hild
(ren
) E
mpl
oyee
& F
amily
A
&M
Den
tal P
PO
9-M
onth
s $3
9.21
$7
8.43
$8
2.35
$1
25.4
8 D
elta
Care
USA
D
enta
l HM
O
9-M
onth
s $2
5.48
$4
5.31
$4
5.67
$7
0.95
V
ision
E
mpl
oyee
Onl
y E
mpl
oyee
& S
pous
e E
mpl
oyee
& C
hild
(ren
) E
mpl
oyee
& F
amily
9-
Mon
ths
$9.3
3 $1
9.84
$1
5.33
$2
7.33
AD
&D
R
ate
per
$10,
000:
Em
ploy
ee O
nly
Em
ploy
ee a
nd F
amily
M
onth
ly*
$.14
$.
24
Lo
ng-T
erm
Disa
bilit
y R
ate
per
$100
of m
onth
ly s
alar
y:
N
on-T
obac
co R
ate
Toba
cco
Rat
e M
onth
ly*
$.17
8 $.
230
Fl
exib
le S
pend
ing
Acc
ount
M
axim
um y
ou c
an d
educ
t fro
m y
our
pay:
Hea
lth C
are
Spen
ding
Acc
ount
- $2
,650
D
epen
dent
Day
care
Spe
ndin
g A
ccou
nt -
$5,0
00
Basic
Life
Th
e pre
miu
m fo
r thi
s pla
n is
usu
ally
pai
d by
the e
mpl
oyer
cont
ribut
ion.
Bas
ic L
ife: $
6.59
A
ltern
ate
Bas
ic L
ife: $
.878
per
$1,
000
of c
over
age
O
ptio
nal L
ife
Y
our a
ge o
n Se
ptem
ber 1
will
be
the
age
used
to c
alcu
late
you
r pre
miu
ms f
or th
e re
st o
f the
fisc
al y
ear.
Mon
thly
rate
per
$1,
000:
A
ge
U
nder
25
25-2
9 30
-34
35-3
9 40
-44
45-4
9 50
-54
55-5
9 60
-64
65-6
9 70
-74
75+
Non
-Tob
acco
Rat
e M
onth
ly*
$.05
$.
05
$.05
$.
06
$.07
$.
12
$.20
$.
36
$.56
$.
76
$1.4
3 $2
.00
Toba
cco
Rat
e M
onth
ly*
$.10
$.
10
$.10
$.
12
$.14
$.
24
$.40
$.
72
$1.1
2 $1
.52
$2.8
6 $4
.00
Dep
ende
nt
Life
Plan
A: S
pous
e A
ge-b
ased
rate
per
$1,
000
of c
over
age;
Chi
ld: $
.06
per $
1,00
0 of
cov
erag
e Pl
an B
: $1.
37/m
onth
(fla
t rat
e)
Plan
C: ½
Alte
rnat
e B
asic
Life
pre
miu
m; 1
/10
if no
spou
se is
cov
ered
A
ge
U
nder
25
25-2
9 30
-34
35-3
9 40
-44
45-4
9 50
-54
55-5
9 60
-64
65-6
9 70
-74
75+
Non
-Tob
acco
Rat
e M
onth
ly*
$.05
$.
06
$.08
$.
09
$.10
$.
15
$.23
$.
43
$.66
$1
.27
$2.0
6 $2
.06
Toba
cco
Rat
e M
onth
ly*
$.06
0 $.
072
$.09
6 $.
108
$.12
0 $.
180
$.27
6 $.
516
$.79
2 $1
.524
$2
.472
$2
.472
*E
mpl
oyee
s de
duct
ed o
ver
9 m
onth
s: A
fter
calc
ulat
ing
your
mon
thly
rat
e, m
ultip
ly th
e ra
te b
y 12
to g
et y
our
annu
al to
tal,
and
divi
de it
by
9 m
onth
s.
34 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
Dependent DocumentationDocumentation is required to add any new dependents.
Legally Married Spouse• Your most recent Federal Tax Return(s) showing
that you are married filing jointly or separately. Financial information should be redacted OR
• *Marriage Certificate AND Proof of Joint Ownership dated less than six months old. Recommendations include Texas Car Insurance Document, assignment of a durable property power of attorney or healthcare power of attorney, a mortgage or bank statement, or property tax bill. Documents must include both the employee’s name and the spouse’s name. *If within two years of marriage, then only the marriage certificate is required.
Common Law Spouse• Texas Declaration of Informal/Common Law
Marriage from the County where the marriage was recognized or recorded, OR
• Your most recent Federal Tax Return(s) showing that you are married filing jointly or separately, AND Proof of Joint Ownership dated less than six months old. Recommendations include Texas Car Insurance Document, assignment of a durable property power of attorney or healthcare power of attorney, a mortgage or bank statement, or property tax bill. Documents must include both the employee’s name and the spouse’s name.
Biological or Adopted Child (adoption com-plete)• Birth Certificate (must show employee’s name as
either the father or mother), OR• Documentation on hospital letterhead indicating
the birth date of the child or children under 6 months old will be accepted as temporary enrollment and must be followed by the birth certificate when received.
Stepchild• Child’s Birth Certificate showing the child’s
parent as the employee’s spouse, AND Marriage Certificate showing legal marriage. If common law marriage, you must provide the documentation as
outlined under Common Law Spouse.
Adopted Child (in progress)• Official court/agency placement papers (initial
stage), OR• Official Court Adoption Agreement for an Adopted
Child (mid-stage)
Grandchild• A document that shows the child’s address is
the same as the employee’s address. Proof of residency must be an official document in the form of:
» For school age children: current year school records for grandchildren of school age and/or a valid driver’s license for grandchildren of driving age, OR
» For non-school age children: currently dated federal or state benefit assistance program record based on residence (such as Medicaid), a court record establishing residence, a copy of the daycare record on the daycare’s letterhead or the part of the social security card with the home address of the child for children not of school age.
*A tax return is NOT proof of residency for a grandchild and will NOT be accepted as appropriate documentation.*Foreign documents other than marriage license or birth certificate should be accompanied by an English translation.
Foster Child• Official Court or Agency Placement papers
Legal Guardianship of a child• Court Order establishing the appropriate legal
relationship.
Managing Conservatorship of a child• Court Order establishing the appropriate legal
relationship.
35 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
Important InformationThe A&M System is committed to protecting your personal health information. The System’s Notice of Privacy Practices is available online at http://assets.system.tamus.edu/files/benefits/pdf/HIPAAprivacy.pdf or from your Human Resources office.
This booklet is a summary of the benefit plans effective September 1, 2018, and does not cover all provisions, limitations and exclusions. The official plan documents, policies and certificates of insurance govern in all cases and are available for your inspection at any time.
Human Resources OfficesTexas A&M University (979) 862-1718 [email protected] A&M Health Science Center (979) 436-9207 [email protected] View A&M University (936) 261-1730 [email protected] State University (254) 968-9128 [email protected] A&M University-Central Texas (254) 519-8015 [email protected] A&M International University (956) 326-2365 [email protected] A&M University-Commerce (903) 886-5049 [email protected] A&M University-Corpus Christi (361) 825-2630 [email protected] A&M University at Galveston (409) 740-4534 [email protected] A&M University-Kingsville (361) 593-4998 [email protected] A&M University-Texarkana (903) 223-3113 [email protected] A&M Transportation Institute (979) 845-9668 [email protected] A&M University-San Antonio (210) 784-2059 [email protected] A&M Forest Service (979) 845-9337 [email protected] A&M AgriLife (979) 845-2423 [email protected] A&M Engineering Experiment Station (979) 458-7699 [email protected] A&M Engineering Extension Service (979) 458-6801 [email protected] Texas A&M University (806) 651-2117 [email protected] Offices (979) 862-1718 [email protected] Phone Numbers and WebsitesBlue Cross and Blue Shield A&M Care; 65 PLUS (866) 295-1212 http://www.bcbstx.com/tamusDelta Dental - A&M Dental (800) 336-8264 http://www.deltadentalins.com/
tamus/DeltaCare USA Dental HMO (800) 422-4234 http://www.deltadentalins.com/
tamus/Superior Vision (844) 549-2603 http://www.superiorvision.comExpress Scripts - A&M Care Drug Program (866) 544-6970 http://www.express-scripts.com/Securian Life Insurance (formerly Minnesota Life) (877) 443-5854 http://www.lifebenefits.com/Navia Benefit Solutions (800) 669-3539 http://naviabenefits.com/Cigna (800) 362-4462 http://cigna.com
Online Enrollment Resources• Check the annual enrollment page at http://www.tamus.edu/business/benefits-administration/open-enrollment/• Review the Benefits Guide at http://assets.system.tamus.edu/files/benefits/pdf/GuideBooklet.pdf• Review the plan books at http://www.tamus.edu/business/benefits-administration/booklets-brochures-forms/
Update Your Life Insurance Beneficiary InformationDon’t forget to log into Workday and update your beneficiaries for your life insurance policy. Log into Workday through Single Sign On, select the Workday link, select the Benefits Worklet, and select “View/Edit Your Beneficiaries”.
36 | The Texas A&M System 2018 Benefits Open Enrollment Guide For Employees
