2017-2018 TRS-ActiveCare Plan Highlights Effective September 1, 2017 through August 31, 2018 ǁ Network Level of Benefits
Type of Service Provider Network
ActiveCare 1-HD Aetna Open Access Choice POS II
ActiveCare 2 Aetna Open Access Choice POS II
ActiveCare Select-Baylor Scott & White Quality Alliance
Scott & White Health Plan HMO
Baylor Scott & White Quality Alliance (EPO)
Scott & White HMO
$1,200 individual / $3,600 family N/A
$1,000 individual / $3,000 family N/A
Deductible (per plan year)
In-Network Out-of-Network
$2,500 employee only / $5,000 family $1,000 individual / $3,000 family $5,000 employee only / $10,000 family $2,000 individual / $6,000 family
Out-of-Pocket Maximum
In-Network (per plan year; includes medical and prescription drug deductibles, copays and Out-of-Network Coinsurance Participant pays after deductible Out-of-Network Office Visit Copay
$6,550 individual / $13,100 family $7,150 individual / $14,300 family $7,150 individual / $14,300 family $6,550 individual / $13,100 family (the individual out-of-pocket maximum only includes covered expenses incurred by that individual) $13,100 individual / $26,200 family $14,300 individual / $28,600 family N/A N/A 20% 20% 20% 20% 40% of allowed amount 20% after deductible
40% of allowed amount $30 copay for primary $50 copay for specialist Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility
N/A $30 copay for primary $60 copay for specialist Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility
N/A $20 copay for primary (1st visit $0 $50 copay for specialist 20% after deductible
Plan pays 100% $40 consultation fee (applies to deductible and out-of-pocket max) 20% after deductible
Plan pays 100% Plan pays 100%
Plan pays 100% Plan pays 100%
Plan pays 100% not covered
$100 copay plus 20% after deductible $100 copay plus 20% after
20% after deductible
20% after deductible
$150 copay per day plus 20% after deductible ($750 max copay per admission; $2250 max copay per plan year)
$150 copay per day plus 20% after deductible ($750 max copay per admission)
20% after deductible 20% after deductible
$50 copay per visit $50 copay per visit $200 copay plus 20% after deductible $200 copay plus 20% after deductible (copay waived if admitted) (copay waived if admitted)
$55 copay per visit $150 copay plus 20% after deductible (copay waived if admitted)
20% after deductible
$150 copay per visit plus 20% after deductible
$150 copay per visit plus 20% after deductible
$150 copay per visit plus 20% after deductible
$5,000 copay (does not apply to outof-pocket max) plus 20% after deductible
not covered
not covered
$0 for generic drugs $200 per person for brand-name drugs
$0 for generic drugs $200 per person for brand-name drugs
$0 for generic drugs $150 per person for brand-name drugs
Participant pays Diagnostic Lab
20% after deductible
Participant pays Preventive Care Teladoc Physician Services High-Tech Radiology
(CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital
(preauthorization required) (facility charges) Participant pays Urgent Care Centers Emergency Room
(true emergency use) Participant pays Outpatient Surgery
$150 copay per day plus 20% after deductible ($750 max copay per admission)
Participant pays $5,000 copay (does not apply to outPhysician charges (only covered if of-pocket max) plus 20% after performed at an IOQ facility) deductible Participant pays Prescription Drugs Subject to plan year deductible Drug deductible (per plan year) Bariatric Surgery
20% after deductible (up to 31-day supply) (deductible and coinsurance waived (up to 30-day supply) for certain generic preventive drugs.) Participant pays · Generic copay $20 $20 $5** · Brand copay (preferred list) $40* $40* 30% after deductible · Brand copay (non-preferred list) $65* 50% coinsurance* 50% after deductible Retail Maintenance 20% after deductible (after first fill; up to a 31 day supply) see below (deductible and coinsurance waived Participant pays for certain generic preventive drugs.) · Generic copay $35 $35 · Brand copay (preferred list) $60* $60* · Brand copay (non-preferred list) $90* 50% coinsurance* Mail Order and Retail-Plus BSWH Pharmacies only 20% after deductible (up to a 90-day supply) (deductible and coinsurance waived Participant pays for certain generic preventive drugs.) · Generic copay $45 $45 $10** · Brand copay (preferred list) $105* $105* 30% after deductible · Brand copay (non-preferred list) $180* 50% coinsurance* 50% after deductible Specialty Drugs 20% after deductible $200 per fill (up to 31-day supply) 20% coinsurance per fill 20% after deductible Participant pays $450 per fill (32 to 90 day supply) *If a brand name drug is dispensed when a generic is available, patient is responsible for generic copay plus cost difference between brand and generic drugs **If a brand name drug is dispensed when a generic is available, 50% copay applies. Bold indicates changes from previous year. Retail Short-Term
