Health Insurance ActiveCare 1-HD, 2 & Select – Aetna 800-222-9205
HMO – Scott & White 800-321-7947
www.trsactivecareaetna.com
In-Network Benefits
www.trs.swhp.org
ActiveCare 1-HD
ActiveCare 2
ActiveCare Select+
Scott & White HMO#
(Participant Pays)
(Participant Pays)
(Participant Pays)
(Participant Pays)
No out-of-network benefits
No out-of-network benefits
$1,200 individual $3,600 family
$1,000 individual $3,000 family
$7,150 individual $14,300 family
$6,550 individual $13,100 family
Deductible must be met before benefits are paid
Medical Benefits
$2,500 Employee Only $5,000 Family
Deductible Maximum Out-of-Pocket
(Includes medical & prescription
deductibles, coinsurance & copays)
$1,000 individual $3,000 family
$6,550 Employee Only $7,150 individual $13,100 Family $14,300 family
Coinsurance
20%
20%
20%
20%
20% (after deductible)
$30 copay - Primary $50 copay - Specialist
$30 copay - Primary $60 copay - Specialist
$20 copay^ - Primary $50 copay - Specialist
Preventive Care
Plan pays 100%
Plan pays 100%
Plan pays 100%
Plan pays 100%
Diagnostic Lab
20% (after deductible)
Quest Facility-Plan pays 100%; Other Facility-20%*
Quest Facility-Plan pays 100%; Other Facility-20%*
20%*
High-tech Radiology
20% (after deductible)
$100 copay & 20%*
$100 copay & 20%*
20%*
Outpatient Surgery
20% (after deductible)
$150 copay & 20%*
$150 copay & 20%*
$150 copay & 20%*
Emergency Room
20% (after deductible)
$200 copay & 20%*
$200 copay & 20%*
$150 copay & 20%*
Inpatient Hospitalization
20% (after deductible)
$150 copay/day & 20%*
$150 copay/day & 20%*
$150 copay/day & 20%*
Teladoc
$40 consultation fee
Plan pays 100%
Plan pays 100%
Not covered
Subject to medical deductible
$0 Generic $200 Brand
$0 Generic $200 Brand
Participant pays (after deductible)
Office Visit Copay
Prescription Drugs Drug Deductible
$200: 31 day supply $450: 32-90 day supply
$489.00 $1,469.00 $837.00 $1,779.00
$20 $40
%Extended-Day @ Mail Order or Retail-Plus
$126.00 $766.00 $446.00 $1,091.00
$45 $105 $180
%Short-Term Maintenance @ Retail Facility
Monthly Premiums Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
$35 $60 $90
@ Retail Facility
20% (after deductible)
$20 $40 $65
%Short-Term
Specialty Drugs
%Extended-Day @ Mail Order or Retail-Plus
20% (after deductible) 20% (after deductible) 20% (after deductible)
%Short-Term Maintenance @ Retail Facility
Tier 1 - Generic Tier 2 - Preferred Brand Tier 3 - Non-Preferred Brand
@ Retail Facility
(Participants deductible does not have to be met)
%Short-Term
Certain Generic Preventive Drugs are Covered 100%
$35 $60 50%
$45 $105
$150 (excludes generic) Maintenance Retail Quantity Quantity (up to 90-day
(up to 30day supply)
supply) @ BSW Pharmacies & mail order
$5
$10 30% 50%
20%
Non-Formulary: $50 or 50% Specialty: 20%
$289.00 $1,039.00 $609.00 $1,364.00
$336.04 $1,038.08 $663.42 $1175.98
* After the deductible has been met +
Visit www.trsactivecareaetna.com to search for providers in 1-HD & 2. For the Select Plan choose the Baylor Scott & White Quality Alliance (DFW Area) option. # Visit www.trs.swhp.org to search for providers in the Baylor Scott & White HMO plan ^ First visit copay for illness waived % Prescription Definitions: Short Term: up to 31-day supply; Extended-Day or Retail-Plus: 60 to 90 day supply: Maintenance: drugs commonly used (daily) to treat conditions (i.e. blood pressure, heart disease, asthma, diabetes, etc.) that are considered chronic or long-term
Visit www.trsactivecareaetna.com to download the Enrollment Guide
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