Open Access Managed Plus plan

Transcription

1 Open Access Managed Plus plan 7T TX (6/17) 1

2 Visit any doctor, no referrals needed A health insurance plan designed to meet your needs Get to know your new Texas Health Aetna plan s This open enrollment, you ll have two benefit plans to choose from a High plan and a Low plan. Both plans are PPO-style plans, called Open Access Managed Plus plans, with in-network and out-of-network coverage. Our Open Access Managed Plus plans let you visit any doctor, anytime you need care. No referrals are needed. And you don t need to choose a primary care physician (PCP) either.* But you may want to, so you can get the most value out of your plan. PCPs do more than give you a checkup. They build a relationship with you and help you stay healthy. Plus, you may even lower your costs by having a PCP. This plan also gives you access to our tools, tips, programs and services. They can help you find network doctors, estimate costs and more. 2 Health benefits and health insurance plans are offered and/or underwritten by Texas Health + Aetna Health Insurance Company (Texas Health Aetna). Texas Health Aetna is an affiliate of Texas Health Resources and of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to Texas Health Aetna. *In Texas, PCP is known as physician (primary care). 3

3 Choosing the right network for you and your family After you select your preferred plan, you ll have two Texas Health Aetna networks to choose from: The broad network consists of the Aetna broad provider network The high-performance, Care, consists of a robust network of local primary care doctors and OB-GYNs, select specialists and high-quality hospitals, including: --1,700+ primary care doctors --4,100+ specialists --49 hospitals --1,300+ behavioral health providers behavioral health facilities And, members of Texas Health Aetna s Care Plus network will enjoy more information and hassle-free conveniences, such as: Personal welcome packets with tips on how to get the most out of their new health plan Prioritized appointments with select primary care doctors More care management tools and local health and wellness services After-hours care at select locations Virtual 24/7 text visits with ER doctors for simple health and prescription needs 4 5

4 Medical benefits snap shot All benefits shown are for in-network care only. Pharmacy benefits snap shot All benefits shown are for in-network care only. Service/feature High plan broad network High plan Care Low plan broad network Low plan Care Service/feature High plan broad network High plan Care Low plan broad network Low plan Care Annual Medical deductible¹ (Individual/family) $2,000/$6,000 $2,000/$6,000 $3,500/$10,500 $3,500/$10,500 Pharmacy out-of-pocket payment limit¹ (Individual/family) $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 Annual out-of-pocket maximum¹ (Individual/family) $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 Preventive care Covered 100% Covered 100% Covered 100% Covered 100% Doctor visit -PCP -Specialists Hospital care -Inpatient (per admission) -Outpatient (per visit) $35 $55 $35 $55 Generic drugs -Retail (up to a 30-day supply) -Mail order (up to a day supply) Preferred brand name drugs -Retail/ Preferred Specialty² -Mail order Non-preferred brand and non-preferred generic name drugs -Retail/Non-preferred Specialty² -Mail order $5 copay $12.50 copay $ copay $ copay $5 copay $12.50 copay $ copay $ copay $15 copay $135 copay $195 copay $15 copay $135 copay $195 copay 6 Emergency room Urgent care $50 $50 ¹ Deductible & out-of-pocket limit covered expenses accumulate separately. No one family member may contribute more than the individual deductible/out-of-pocket limit amount to the family deductible/out-of-pocket limit. Once the family deductible/out-of-pocket limit is met, all family members will be considered as having met their deductible/out-of-pocket limit for the remainder of the calendar year. ¹Deductible & out-of-pocket limit covered expenses accumulate separately. No one family member may contribute more than the individual deductible/out-of-pocket limit amount to the family deductible/out-of-pocket limit. Once the family deductible/out-of-pocket limit is met, all family members will be considered as having met their deductible/out-of-pocket limit for the remainder of the calendar year. ²Up to a 30-day supply from Aetna Specialty Pharmacy Network. First prescription fill at any retail or specialty pharmacy. Subsequent fills must be through our preferred Aetna Specialty Pharmacy network. 7

5 8 Tools to help you find network doctors and more For help over the phone You can speak to Member Services anytime during regular business hours. Our representatives are here to help answer any questions you have about your plan. Just call the toll-free number on your member ID card. Meet Ann, your virtual assistant Ann can help you sign up for your secure member website. She can help you find a doctor, estimate the cost of health services, and even answer questions about claims, ID cards and more. She never sleeps so chat with her anytime. Finding a PCP or network doctor is easy Use our online directory. To find a doctor in the Texas Health Aetna network, simply visit and click the Find a Doctor quick link. Under Find a Doctor or Facility, enter a name, specialty, procedure or condition or enter a ZIP code or city and state to search within a certain area You can also choose from the list of common searches for providers, conditions and procedures Select your plan name from the drop-down menu --For Care providers, select Open Access Managed Plus under Employer Plans Care Plus --For broad network providers, select Open Access Managed Plus under Employer Plans Once you make your selection, your results will appear Providers listed under the Best Results for Your Plan tab will offer you the lowest out-of-pocket expense Or get a printed directory. If you are already a member, call Member Services to get one. The toll-free number is on your member ID card. If you are not a member yet or have not received your ID card visit our website at Here s a way to estimate costs once you enroll Our Member Payment Estimator tool lets you compare and estimate costs* for office visits, tests and surgeries. This online tool factors in any deductible, coinsurance and copays that are part of your plan, plus our contracted rates. You can see how much you ll have to pay and how much Texas Health Aetna will pay. To use the estimator tool, go to and log in to your secure member website. Sign up for your members-only website When you re a member, you get tools and resources to help you manage your health and your benefits. You ll find all your plan information and cost-saving tools in one place your secure member website. You just need to sign up. Members can register at * Estimated costs not available in all markets. The tool gives you an estimate of what you would owe for a particular service based on your plan at that very point in time. Actual costs may differ from the estimate if, for example, claims for other services are processed after you get your estimate but before the claim for this service is submitted. Or if the doctor or facility performs a different service at the time of your visit. 9

6 Get a plan with freedom of choice for you and your family. For more information, call or visit 10

7 TTY: 711 Para obtener asistencia lingüística en español, llame sin cargo al 1-XXX-XXX-XXXX. (Spanish) 欲取 得繁體中文語言協助, 請撥打 1-XXX-XXX-XXXX, 無需付費 (Chinese) Aetna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. If you require language assistance, please call the Member Services number on your member ID card, and a representative will connect you with an interpreter. If you re deaf or hard of hearing, use your TTY and dial 711 for the Telecommunications Relay Service. Once connected, please enter or provide the telephone number you re calling. Si usted necesita asistencia lingüística, por favor llame al número de Servicios al Miembro que figura en su tarjeta de identificación de miembro, y un representante le conectará con un intérprete. Si usted es sordo o tiene problemas de audición, usar su TTY y marcar 711 para el Servicio de Retransmisión de Telecomunicaciones. Una vez conectado, por favor entrar o proporcionar el número de teléfono que está llamando. This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Health insurance plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not our agents. Provider participation may change without notice. Physicians on the medical staff practice independently and are not agents or employees of the hospital or Texas Health Resources. We do not provide care or guarantee access to health services. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Texas Health Aetna plans, refer to Aetna Inc. 7T TX (6/17)