1. Plan 1- Base Plan Information
McLennan County Employee Health Plan Benefits
Plan Year
Plan 1- Base Plan Information

2. What’s New for 2016-2017 Plan Year
Information you should know about your health plan renewal for October 1st:
McLennan County Commissioners Court approved no changes to the health plan. The County will continue to contribute $ to the total cost of the plans’ monthly premium for the Plan 1 Base Plan.
McLennan County Commissioners Court approved no changes to the health plan. The County will continue to contribute $ to the total cost of the plans’ monthly premium for the Plan 2 CDHP Plan and also will contribute $43.54 to the HSA monthly.
(For retirees, the County will contribute $ to the retiree only premium for employees that had 20 consecutive years of service at retirement) 2

3. What is a deductible and when does it apply?
A deductible is the amount you pay for covered health care services before your insurance plan starts to pay. With a $1,000 deductible, for example, you pay the first $1,000 of covered services yourself. The only services that are not subject to the deductible are the ones with a co-pay stated in the plan summaries. The CDHP benefits are subject to the deductible before the plan pays. The only benefits that are not subject to the deductible for the CDHP are the age appropriate preventative services and the RX co-pays from the approved preventative drug list.
McLennan County’s Health Benefit Plan starts October 1, 2016, and runs through September 30, 2017.
Deductibles for both the Base Plan and the Consumer Driven Health Plan run from January 1 to December 31. Your deductible does not start over until January 1.
If you have met a part of your deductible prior to October 1 it will carry over until December 31 and then start over on January 1, 2017.
Scott and White recently expanded to cover TRS-Active Care members in North Texas. However, we have a long tradition of meeting TRS-Active Care members’ needs.
Source: Guide to Texas HMO Quality: 2014 3

4. PLAN 1 – Base Health Plan Effective October 1, 2016 Employee Only Premium $28.09
Benefit
In-network
Calendar Year Deductible (Applies to Out-of-Pocket Maximum)
Individual Deductible
Family Deductible
(Family deductible is embedded)
$1,000
$2,000
Calendar Year Out-of-Pocket Maximum
Individual Out-of-Pocket Maximum
Family Out-of-Pocket Maximum
$4,500
$9,000
Primary Care Office Visit
$30 office copay
Specialty Care Office Visit
$50 office copay
Treat-n-Go Walk-In Clinic
$10 copay
Allergy Serum
20% after deductible
Outpatient Surgery
Standard Lab and X-Ray
No Charge
Other Outpatient Services (Including other services, treatments, or
procedures received at time of visit)
Preventive Care Services (See list for full details)
Skilled Nursing Facility (Pre-Certification Required)
20% after deductible (Unlimited)
Scott and White recently expanded to cover TRS-Active Care members in North Texas. However, we have a long tradition of meeting TRS-Active Care members’ needs.
Source: Guide to Texas HMO Quality: 2014 4

5. 20% after deductible (Unlimited)
PLAN 1 – Base Health Plan Effective October 1, Employee Only Premium $28.09
Benefit
In-network
Eye Exam (1 refraction annually)
$30 office copay
Copay for each day of Skilled Nursing Facility inpatient services.
Max Skilled Nursing Facility days per year.
20% after deductible (Unlimited)
Inpatient Services
Hospital Room, Semi-private
20% after deductible
Intensive Care Unit
Other Hospital Services
Emergency Care Services
(could be balanced billed for services out of network)
Emergency Room (In and out of area)
Urgent Care (In and out of area)
$50 copay
Ambulance
Outpatient - Mental Health/Chemical Abuse Services
Serious Mental Illness (Requires referral and approval
of medical director)
$30 copay
Inpatient - Mental Health/Chemical Abuse Services
/Inpatient Serious Mental Illness (Requires referral and
approval of medical director)
Scott and White recently expanded to cover TRS-Active Care members in North Texas. However, we have a long tradition of meeting TRS-Active Care members’ needs.
Source: Guide to Texas HMO Quality: 2014 5

6. PLAN 1 – Base Health Plan Effective October 1, 2016 Employee Only Premium $28.09
Benefit
In-network
Therapeutic Services Speech & Hearing visit
Max Speech & Hearing visits per year
$30 copay
20 visits per year
Physical Therapy visit
Max Physical Therapy visits per year
Home Health Services (Precertification Required)
$30 copay unlimited
Home Infusion Therapy (Precertification Required)
20% co-insurance
Hospice Services (Precertification Required)
20% co-insurance (unlimited)
Maternity Services (Pre-Natal visits)
No Charge
Diagnostic Procedures in conjunction with Maternity Services
20% after deductible
Outpatient Diagnostic Procedures in conjunction with Family Planning Services.
Durable Medical Equipment/Orthotics/Prosthetic Medical Appliances
50% after deductible
Inpatient Prescription Drugs Includes Specialty Pharmacy Drugs administered in an inpatient setting.
Same as other inpatient services
Diagnostic/Radiology (Limited to: angiograms, CT scans, MRIs, PET scans, myelography, stress tests, ultrasound)
Diabetic Supplies, Equipment, and Self-Management Training
Same as DME or Rx, as appropriate
$30 copay for self-mgmt training
Source: Guide to Texas HMO Quality: 2014 6

7. PLAN 1 – Base Health Plan Prescription Benefits
In-network
Annual Deductible
No deductible for Rx
Generic Drugs
$10 copay
Preferred Brand
$30 copay
Non-Preferred
Lesser of $55 or 50%
Non-Formulary
Greater of $55 or 50%
Generic (Maintenance Drugs; 3 Months Supply)
$20 copay
Preferred Brand (Maintenance Drugs; 3 Months Supply)
$60 copay
Non-Preferred (Maintenance Drugs; 3 Months Supply)
Lesser of $110 or 50%
Non-Formulary(Maintenance Drugs)
Not Applicable
Outpatient Specialty Drugs
(Deductible does not apply)
Level 1
10% copay
Level 2 (Preferred)
20% copay
Level 3 (Premium Preferred)
30% copay
Level 4 (Non-Preferred)
50% copay
Source: Guide to Texas HMO Quality: 2014 7

8. Examples of How “Plan 1: Base Health Plan” Works
If you have to go into the hospital, you will have to pay the first $1,000 of charges and then you will have to pay 20% of the remaining charges until you have reached the out-of-pocket max. of $4,500.
If you have a CT scan you will have to pay the first $1,000 of charges, then 20% of the remaining charges until you reach the $4,500.
If you pay a copay for your office visit, you pay $500 for a sonogram test, then have a CT scan ,expect to pay another $500 of charges to satisfy the remaining deductible amount. Should you go into the hospital, you will have to pay 20% of the charges until the amounts that you have already paid and the 20% adds up to your out-of-pocket max. of $4,500.
In August, you have an office visit with a copay of $30; and at that visit you also have a procedure such as having a mole removed. The charges for that are $85, you will pay a total of $115. The $85 will apply to the deductible, but the $30 will apply to the out-of-pocket maximum. In September, the doctor says that you need to have a MRI for your back and those charges are $2,900, you will pay $915 to meet the remaining deductible amount plus 20% being $397. On Nov. 10th, you go into the hospital and those charges are $13,000, you will have to pay 20% which is $2,600. You have met the deductible, but still have $473 of the out-of-pocket maximum to meet. Remember the deductible and out-of-pocket maximum will start over again on January 1st.
** Disclaimer: costs on these slides are fictitious and only for purposes of explaining how the plan works.

9. Examples of How “Plan 1: Base Health Plan” Works Continued
Diabetic services example: Diabetic supplies that cost $65 per month, coverage is at 50% of the copay. If you go to the doctor every month for 3 months and the amount for the copay is $30 plus you have the monthly diabetic supplies, you will pay $ Then on October 5th, you have to go into the hospital for outpatient surgery unexpectedly. When you receive the bill for the out patient surgery of $5,600, you will have to pay $1,000 deductible and 20% of the remaining charge which is $920 of the $5,600 billed from the provider. You have satisfied the deductible; however, only $ of the out-of-pocket was used for the calendar year. You will still be expected to pay $ of the remaining out-of-pocket maximum should you have additional services rendered before the end of the calendar year which ends in December.
Please remember that if you have any services done out-of-network there are no benefits paid.
** Disclaimer: costs on these slides are fictitious and only for purposes of explaining how the plan works.

10. Prescription Coverage
Is My Prescription covered and what will I have to pay? Calling or ing our Scott & White Health Plan Pharmacy Team will help you with your questions: or
If you have questions about your prescription drug coverage, we’ll be there to help. Just go to our website or give us a call. 10

11. Get Preventive! Preventive Services Create a schedule of vaccines.
Scott & White Health Plan encourages you to
Get Preventive!
Find providers in our network, manage your accounts with us, and learn what SWHP has to offer at: SWHP.org
For recommended preventive services for:
Adults Women Pregnant Women Children
Create a schedule of vaccines.
Birth to six years
Make a schedule of recommended immunizations for your child from birth through 6 years. Review the schedule with your child’s doctor.
Take an online vaccination quiz.
11 years and older
Take the quiz to see which vaccines you or your child may need.
English:
Spanish:
Source: Guide to Texas HMO Quality: 2014

12. Wellness Program Options
Wellness Assessment
For Members and Non-Members
Lifestyle Management Programs
Balance
Nourish
Relax
Breathe
Care for Depression
Dream
Care for Your Health
Care for Pain

13. SW Health Plan Service Enhancements For 2016-2017
SWHP portal information optimized for smartphone
Improved member website: http//:mclennan.swhp.org
Nationwide Pharmacies
Scott and White Health Plan is working to keep costs in check while offering the tools and resources you need to access your health care coverage when and where you need. 13

14. S&W Health Plan Online Tools
Through the member portal account at swhp.org,or through the McLennan County page at mclennan.swhp.org then click on the login button, members can:
See required copays
Print an ID card or request a new one
Check the status of deductibles and out-of-pocket max 
See claims and Explanations of Benefits (filtered by member/dependent)
Get information on specific providers
Review prescription usage
Members can also send an to customer service advocates and receive responses through the portal’s secure messaging feature.
The information noted above is available through you member portal, which can be accessed just as easily from a computer, tablet, or smartphone. 14

15. Member Portal Services mclennan.swhp.org
Members can sign up for a member portal account or log in to their account at mclennan.swhp.org.

16. Member Portal Services FAQ
Find commonly asked questions under Frequently Asked Questions. If you need to contact us please reach out to us at

17. Thank you!