Transcript Medical Plan I

Page 1
Pasadena
ISD
Page 2
PISD Benefits
Contact Numbers
1515 Cherrybrook – Pasadena 77502
Summer Hours:
Monday – Thursday
7:00a.m. – 5:30p.m.
Cecilia Beltran
Nancy Silvestre
Vonnie Conde
713-740-0110
713-740-0120
713-740-0121
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Enrollment and Coverage
Your health coverage begins the first day you are on duty. However …
o If you choose to have coverage beginning in August, you must write out
a check for the August premium.
o If you choose coverage to begin Sept 1, you do not need to do
anything. Your premium will come out of Sept checks.
“Voluntary plans” ( Disability, Dental, Cancer etc.) coverage begins the first
day of following month
 Elections you choose now (at your Human Resources appt.) carry you
through December 31,2013.
o Annual Enrollment (to make changes to your elections) begins in the
fall. Those changes go into effect 01/01/2014. Coverage is from Jan 1
– Dec 31.
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Payroll Information
(refer to sheet in packet)
 Premiums are taken out of both checks equally.
o Check dates are 1st of the month, and 15th of the
month.
Health Insurance Options are:
o Medical Plan I - Aexcel Aetna Choice POS II
o Medical Plan II – Aetna CPOS II Healthfund
o Plan III - Alternate Plan (no health insurance with
us)
o Medical Plan IV – Aetna CPOS II HRA - ACD
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Medical Plan I – Aexcel Aetna CPOSII
Network
In-Network
Out-Network*
HealthFund Amount contributed by
Pasadena ISD
N/A
N/A
Plan Coinsurance
20%
50%
$750 per person
$2,250 per family
$2,250 per person
$6,750 per family
$2
$7
---------$4,000 per person
$3,500
$12,000 family
$12,000 per person
$36,000 family
$5,
$
Unlimited
Unlimited
$35 copay
50% after deductible
20%
$50 copay
50% after deductible
20%
Specialty Care - Office Visits
Non-Aexcel Designated
$65 copay
50% after deductible
20%
Specialty Care - Office Visits
All other Specialists
$50 copay
50% after deductible
20%
Calendar Year Deductible
Individual
Family
Out-of-Pocket Maximum
Individual
Family
Lifetime Maximum Benefit
Primary Care Physician (PCP)
Office Visits
Specialty Care - Office Visits
Aexcel Designated
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Medical Plan I – Aexcel Aetna CPOSII
Cont’d
Preventive Care Annual routine
physical:Adult and Well Child, GYN,
Mammograms, Colorectal Cancer
Screenings,PSA Tests
100%
50% after deductible
PCP or Specialist copay
50% after deductible
20% aft
100%
50% after deductible
20% aft
20% after deductible
50% after deductible
20% aft
$500 per confinement copay,
then 20%
after deductible
$500 per confinement copay,
then 50%
after deductible
20% aft
Outpatient Surgery
$100 copay, then 20%
after deductible
$100 copay, 50% after
deductible
20% aft
Emergency Room
Copay/Coinsurance
(Copay waived if admitted)
$250 copay, then 20%
after deductible
same as preferred care
$250 cop
after
20% after deductible
same as preferred care
20% aft
$50 copay
50% after deductible
20% aft
$25 copay
50% after deductible
20% aft
Diagnostic Outpatient Lab/
X-rays/Testing (part of office visit)
Diagnostic Outpatient Lab/
X-rays/Testing (Facility)
Complex Imaging Services
Inpatient Hospital Services
Ambulance
Urgent Care Copay/Coinsurance
(Copay waived if admitted)
Walk In Clinics
1
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Medical Plan I – Aexcel Aetna CPOS II
Monthly Premiums
District’s
Contribution
Employee’s
Cost
Employee Only
$245
$250
Employee & Spouse
$245
$650
Employee & Child(ren)
$245
$510
Family
$245
$895
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Medical Plan II – Aetna CPOSII
AHF-HRA
Network
In-Network
HealthFund Amount contributed by
Pasadena ISD
$500 Employee/yr
$1,000 EE+S, Ch or F
Plan Coinsurance
20%
Out-of-Network
($41.66/mo for Aug newhires)
($83.33/mo for Aug newhires)
50%
Calendar Year Deductible
Individual
Family
$2,500 per person
$7,500 per family
$7,500 per person
$22,500 per family
Out-of-Pocket Maximum
Individual
Family
$5,000 per person
$15,000 family
$15,000 per person
$45,000 per family
Lifetime Maximum Benefit
Primary Care Physician (PCP)
Office Visits
Specialty Care Office Visits
Aexcel Designated
Unlimited
Unlimited
20% after deductible
50% after deductible
20% after deductible
50% after deductible
Specialty Care Office Visits
Non-Aexcel Designated
20% after deductible
50% after deductible
Specialty Care Office Visits
All other Specialists
20% after deductible
50% after deductible
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Medical Plan II – Aetna CPOSII
AHF-HRA (cont’d)
Preventive Care Annual routine
physical:Adult and Well Child, GYN,
Mammograms, Colorectal Cancer
Screenings,PSA Tests
100%
50% after deductible
20% after deductible
50% after deductible
20% after deductible
50% after deductible
20% after deductible
50% after deductible
Inpatient Hospital Services
20% after deductible
50% after deductible
Outpatient Surgery
20% after deductible
50% after deductible
$250 copay, then 20%
after deductible
same as preferred care
20% after deductible
same as preferred care
20% after deductible
50% after deductible
20% after deductible
50% after deductible
Diagnostic Outpatient Lab/
X-rays/Testing (part of office visit)
Diagnostic Outpatient Lab/
X-rays/Testing (Facility)
Complex Imaging Services
Emergency Room
Copay/Coinsurance
(Copay waived if admitted)
Ambulance
Urgent Care Copay/Coinsurance
(Copay waived if admitted)
Walk In Clinics
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Medical Plan II – Aetna CPOS II AHF-HRA
Monthly Premiums
District’s
Contribution
Employee’s
Cost
Employee Only
$245
$135
Employee & Spouse
$245
$335
Employee & Child(ren)
$245
$260
Family
$245
$495
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Medical Plan III – Alternate Plan
I. Hospital Income
Inpatient Hospital Days
$150 per day/Benefit Maximum
180 Days per Calendar Year
II. Life and Accidental Death and Dismemberment Insurance
Employee covered under the Alternate Plan receive an additional $10,000 in life insurance
III. Dental Coverage – Sun Life Financial
Deductible per year - $50
Calendar Year Max. Benefits - $1,000
* Preventative & Diagnostic Dental Services – 100% of Usual & Customary Charges
Periodic Oral Exam, Bite0Wing X-Rays, Dental Prophylaxis Cleaning, Complete Series or Panorex
* Basic Dental Services (Minor Restorative, Endodontic, and Oral Surgery) – 80% of Usual & Customary
Charges
Fillings, Root Canal Treatment, Root Planning, Periodontal Surgery, Simple Extraction, Surgical Extraction
* Major Dental Services – 50% of Usual & Customary Charges
Crowns, Fixed Bridges, Full Dentures, Inlay & On lays, Partial Dentures, Relining Dentures,
Repairs to Full Dentures, Partial Dentures, Bridges
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Medical Plan IV – Aetna Select
MEMORIAL HERMANN ,
Network
HealthFund Amount contributed by
Pasadena ISD
Plan Coinsurance
Calendar Year Deductible
Individual
Family
Out-of-Pocket Maximum
Individual
Family
Lifetime Maximum Benefit
Primary Care Physician (PCP)
Office Visits
Specialty Care Office Visits
Aexcel Designated
ST. LUKES, and HCA
FACILITIES ONLY
Out-of-Network
$500 Employee/yr ($41.66/mo for Aug newhires)
$1,000 EE+S, Ch or F ($83.33/mo for Aug newhires)
N/A
20%
N/A
$2,500 per person
$7,500 per family
$5,000 per person
$15,000 family
Unlimited
20% after deductible
N/A
N/A
N/A
N/A
20% after deductible
N/A
Specialty Care Office Visits
Non-Aexcel Designated
20% after deductible
N/A
Specialty Care Office Visits
All other Specialists
20% after deductible
N/A
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Medical Plan IV – Aetna Select
Cont’d
Preventive Care Annual routine
physical:Adult and Well Child, GYN,
Mammograms, Colorectal Cancer
Screenings,PSA Tests
100%
N/A
20% after deductible
N/A
20% after deductible
N/A
20% after deductible
N/A
Inpatient Hospital Services
20% after deductible
N/A
Outpatient Surgery
20% after deductible
N/A
$250 copay, then 20%
after deductible
same as preferred care
20% after deductible
same as preferred care
20% after deductible
N/A
20% after deductible
N/A
Diagnostic Outpatient Lab/
X-rays/Testing (part of office visit)
Diagnostic Outpatient Lab/
X-rays/Testing (Facility)
Complex Imaging Services
Emergency Room
Copay/Coinsurance
(Copay waived if admitted)
Ambulance
Urgent Care Copay/Coinsurance
(Copay waived if admitted)
Walk In Clinics
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Medical Plan IV – Aetna Select
Monthly Premiums
District’s
Contribution
Employee’s
Cost
Employee Only
$245
$100
Employee & Spouse
$245
$251
Employee & Child(ren)
$245
$210
Family
$245
$395
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Aetna Member Resources
Group Plan Number: 838899
Member Services Toll Free Number
1-800-841-3541
Claims Address: P.O. Box 981106, El Paso TX 79998-1106
Remember to Register on Aetna Navigator
o How to Register - Registration is an easy process:
o Go to www.aetna.com and click on "Register" under "Aetna
Navigator® Member Log In"
o Complete the requested information
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What is Aexcel*?
Aexcel is a designation for specialty doctors who are some of the high
performers in their specialty areas.
It’s easy to find Aexcel-designated doctors - just look for the star 
next to their names in DocFind®
How do specialist qualify for the Aexcel designation?
• Are part of the existing Aetna network of health care providers
• See enough Aetna patients to allow us sufficient data to review their performance
• Have met industry-accepted practices for clinical performance
• Have met Aetna’s efficiency standards
• As the final step, we make sure there are enough specialists for members to choose from
*Aexcel is not available with HMO plans.
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Aexcel-designated doctors are in
12 specialty areas
 Cardiology
 Obstetrics / Gynecology*
 Cardiothoracic Surgery
 Orthopedics
 Gastroenterology
 Otolaryngology/ENT
 General Surgery
 Plastic Surgery
 Neurology
 Urology
 Neurosurgery
 Vascular Surgery
*Ob/Gyns are classified as specialists in the Aetna plan.
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How to Find a PCP
DocFind –
o Go to www.aetna.com and click on doc find.
www.aetna.com/docfind/custom/pasadenaisd
o Select your provider category. You can search by city, state, zip,
specialty, hospital affiliation, provider name, gender, language and
education.
o Select the “Aexcel Choice POSII Open Access” network for Medical I
o Select the “Aetna Choice POSII (Aetna Health Fund)” network
Medical II
o Select the “Open Access Aetna Select (Aetna Health Fund)” network
Medical IV
o Click on search to find a provider
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Custom DocFind makes it easier for you to find
an Aexcel-designated specialist
999 Shore Rd.
Suite N999
Anywhere, CT, 06457
(860)123-3456
Allan, Michael, MD
999 Shore Rd.
Suite N999
Anywhere, CT, 06457
(860)123-3456
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Docfind Provider View Details
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Express Script
Pharmacy Benefits
Participating Pharmacy – up to 30 days supply
Tier 1: Generic Drug
$15 Co-Pay
Tier 2: Preferred Brand Drug
$40 Co-Pay
Tier 3: Non-Preferred Drug
$70 Co-Pay
Home Delivery – up to 90 days supply
Tier 1: Generic Drug
$30 Co-pay
Tier 2: Preferred brand drug
$80 Co-pay
Tier 3: Non-preferred brand drug
$140 Co-Pay
**Plan 1 includes the following deductible (combined Tier 2 & Tier 3 drugs only)
$100 deductible per person
$150 deductible for family
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Other P.I.S.D Employee Benefits
Resources:
 Monthly Newsletter
 Website
o Insurance Contact phone numbers and web links
o FAQ’s
o Documents and claim forms for download
o Information on your health plan
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Pasadena ISD Wellness Center
1850 E. Sam Houston Parkway, Pasadena TX 77503
Clinic Hours are
Monday, Wednesday, Friday: 8 am—4 pm
Tuesday and Thursday: 1pm—8pm
Saturday: 8am—1pm
Call 713-740-5300 for an appointment
or visit www.pasadenaisdclinic.com
Employees on our health plan can receive services at the
clinic at no cost. (Family members eligible also)
 Employees not on our health plan will pay the copay based on
their insurance plan.
 Employees with NO INSURANCE will have $50 copay.
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QUESTIONS …
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Mr. Whitney Miller
1-800-876-9070