Scott & White Health plans Texas

Health Maintenance Organizations (HMO) An HMO gives you a range of benefits for a prepaid monthly fee. The plan focuses on wellness, prevention, and treatment within a network of providers. Out-of-network providers are usually not covered, unless in an emergency. Preferred Provider Organizations (PPO) PPOs often have a larger network of providers. This option can offer the greatest flexibility for members seeking care in and out of network. If a member visits an in-network doctor, they’re only responsible for their annual deductible and copay. If a member gets care outside the network, benefits may be reduced and their copay may be higher. Often, annual deductibles for PPO plans are higher than deductibles for HMO plans.

	Bronze HMO 6400/50v	Bronze PPO 7150
Benefit	HMO Plan In Network (No Out of Network)	PPO In Network	PPO Out of Network
Plan CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max	80%	100%	50%
Member CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max	20%	0%	50%
Individual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. 1 Family Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.	$6,400 $12,800	$7,150 $14,300	$14,300 $28,600
Individual Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services 2 Family Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services	$7,150 $14,300	$7,150 $14,300	$14,300 $28,600
Primary Care Office Visit	$50 copay (first visit)	$60 copay (first 2 visits)	Deductible then 50%
Specialist Office Visit	Deductible then 20%	$100 copay (first 2 visits)	Deductible then 50%
Urgent Care	$50 copay (first visit)	Deductible then 0%	Deductible then 0%
Emergency Room	Deductible then 20%	Deductible then 0%	Deductible then 0%
Imaging (PET, CT, MRI)	Deductible then 20%	Deductible then 0%	Deductible then 50%
Outpatient Lab and X-Ray	Deductible then 20%	Deductible then 0%	Deductible then 50%
Inpatient Hospitalization	Deductible then 20%	Deductible then 0%	Deductible then 50%
Pharmacy Deductible	None	None	None
Preferred Generic Drugs	$17 copay	$40 copay	Deductible then 50%
Preferred Brand Drugs	Deductible then 50%	$100 copay	Deductible then 50%
Non-Preferred Brand	Deductible then 50%	Deductible then 50%	Deductible then 50%
Specialty Drugs	Deductible then 50%	Deductible then 50%	Deductible then 50%
(1 ) Deductibles and out-of-pocket responsibility apply per calendar year.
(2) All member responsibility for copays, deductibles, and coinsurance apply to the out-of-pocket maximum. Preventive medications are covered in full – deductible and coinsurance do not apply.
The PPO plan includes coverage when out-of-network providers are used; however, you will be responsible for any amounts above the allowed charges. These amounts can be billed to you by the provider and do not apply to your annual out-of-pocket maximum under the plan.
SCOTT AND WHITE HEALTH PLAN and the INSURANCE COMPANY OF SCOTT AND WHITE ARE QUALIFIED HEALTH PLAN ISSUERS.