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Benefits

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Benefits Descriptions

Comprehensive Services for You and Your Family

Review the plan benefits and service premiums below and get on your way to comprehensive health care from Scott & White Health Plan. To sign up, fill out the FEHBP enrollment form (SF-2809) indicating the enrollment you want and return the form to your personnel office.

You can also learn more about federal health insurance through the Office of Personnel Management website.

This information is effective January 1, 2017 for the 2017 plan year.


Individual Deductible Options
Self only $0
Self Plus one $0
Self and family $0
Out-of-Pocket Maximum
Self only $4,500
Self Plus one $9,000
Self and family $9,000
Doctor Office Visits
Primary care visits to treat an injury or illness $20 copay/visit
Specialist visit $45 copay/visit
Other practitioner office visit $45 copay/visit
Preventive care/screening/immunization No charge
Emergency Medical Care
Urgent care visit

$50 copay/visit

Emergency room services $250 copay/visit
Emergency medical transportation $125 copay/visit
Services Provided by a Hospital
Inpatient $250 per day
up to a maximum of $750 per admission
Outpatient $250/visit
Medical Testing
Diagnostic test
(X-ray, blood work)
No charge
Imaging
(CT/PET scans, MRIs)
$100 per procedure
Dental Care
Discounts available through Careington International Corporation 20%-50% discounts

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Prescription Drug Coverage
Preferred generic drugs $6 copay/retail, non-maintenance
$12 copay/mail order, maintenance
Covers up to a 30-day supply or 100 units (retail prescription); and the lesser of 90-days or 360 units (mail order prescription)
Preferred brand drugs $50 copay/retail, non-maintenance

$100 copay/mail order, maintenance

Covers up to a 30-day supply or 100 units (retail prescription); and the lesser of 90-days or 360 units (mail order prescription)
Non-preferred & non-formulary $100 or 50% copay,
whichever is greater/retail,
non-maintenance.
$250 per RX cap
Covers up to a 30-day supply or 100 units (retail prescription)
Specialty drugs $250 copay/non-maintenance Failure to obtain pre-authorization may result in the denial of coverage for this service. Please consult swhp.org or call 800-321-7947 to verify pre-authorization requirements.
Premium Options
Central and West Texas   Non-Postal Premium Postal Premium
    Biweekly Monthly Biweekly
Type of enrollment Enrollment code Gov’t share Your share Gov’t share Your share Category 1 your share Category 2 your share
Standard option self only A84 $221.67 $91.47 $480.29 $198.18 $82.24 $79.16
Standard option self plus one A86 $475.79 $180.11 $1,030.88 $390.24 $160.28 $153.68
Standard option self and family A85 $505.22 $228.58 $1,094.64 $495.26 $207.52 $200.51

 

North Texas   Non-Postal Premium Postal Premium
    Biweekly Monthly Biweekly
Type of enrollment Enrollment code Gov’t share Your share Gov’t share Your share Category 1 your share Category 2 your share
Standard option self only P84 $221.67 $128.87 $480.29 $279.21 $119.64 $116.56
Standard option self plus one P86 $475.79 $258.64 $1,030.88 $560.39 $238.81 $232.21
Standard option self and family P85 $505.22 $316.45 $1,094.64 $685.65 $295.39 $288.38