Medical Plan Options

UT offers UT SELECT, a self-funded medical PPO plan, and HMO Blue Texas, a fully insured HMO plan, both administered by Blue Cross and Blue Shield of Texas, Inc.

IMPORTANT: If you live in Galveston County and are employed at UT MD Anderson Cancer Center or UT Health Science Center-Houston and currently enrolled in HMO Blue, you and your covered dependents may choose to continue participation in HMO Blue. All other residents of Galveston County currently enrolled in HMO Blue will be automatically enrolled in UT SELECT effective September 1, 2005.

Transitional Benefits

If you decide to change your medical plan during Annual Enrollment and you are currently being treated for a chronic or ongoing medical condition, you may be eligible for Transitional Benefits. This means if your doctor is a contracting provider with your current medical plan but is not a contracting provider with your new plan, you may be allowed to continue seeing your current doctor for up to 3 months, and your claims will be paid at your new plan’s Network benefit level.

Transitional Benefits give you the opportunity to find a new Network provider while not risking the loss of medical care. Some medical conditions that are eligible for Transitional Benefits consideration include:

• Pregnancy (if you are in your 3rd trimester on September 1 for UT SELECT and 2nd trimester on September 1 for HMO Blue Texas)**
• Cancer
• Heart Failure
• Diabetes
• Physical Therapy
• Allergy Treatments
• Organ Transplant
• Behavioral Health Care

** Galveston County Residents currently enrolled in HMO Blue and in their 3rd trimester of pregnancy on September 1, 2005 will receive HMO benefits for maternity care under UT SELECT.

A Transition of Care form must be completed and mailed to the new Medical Plan administrator for consideration.

New UT SELECT Plan Features

Beginning September 1, 2005, UT SELECT will offer new disease management programs from Blue Cross and Blue Shield of Texas for health and medical decision-making and self-management. The disease management programs are available at no additional cost and can address the conditions listed below from early stages or mild symptoms to chronic cases with the most severe symptoms.

• Asthma
• Diabetes
• Coronary artery disease
• Congestive heart Failure
• Chronic obstructive pulmonary disease–chronic bronchitis, emphysema
• Metabolic syndrome–high blood pressure, high cholesterol
• Lower back pain
• End stage renal disease

Also new for UT SELECT:

CareWise 24-Hour NurseLine – a staff of trained, experienced registered nurse counselors available 24/7 to answer health care questions and provide information about a wide variety of health care issues and medical, non-emergencies. To talk to a CareWise nurse, call toll-free: 1-888-315-9473.

Special Beginnings® – a comprehensive prenatal program that helps mothers take better care of themselves and their babies. The program assesses pregnancy risk level and provides close monitoring through a series of calls from an experienced obstetrical nurse from pregnancy through six weeks after delivery. To enroll or ask questions about the program, call toll-free: 1-800-462-3275.

Blue Access® for Members

Blue Access for Members offers you and your family better tools for better health. Just log onto www.bcbstx.com/ut and select the link for Blue Access for Members. Then click on the My Health tab, then on the Mayo Clinic* logo to research specific health conditions, get advice on how to start an exercise program, or start a program to stop smoking or lose weight. You can also take the Mayo Clinic Health Risk Assessment (HRA), a confidential tool that helps you learn more about your individual health risks. Select the link, Take the HRA now!

and follow the prompts to complete the assessment. When you’re finished, you’ll receive a personalized health report online, complete with confidential feedback on possible health issues and how to address them.

The relationship between Blue Cross and Blue Shield of Texas and Mayo Clinic is solely that of independent contractors.

You may read additional information about plan features and exclusions in the Medical Plan certificates available on this Website or at your campus Benefits Office.

Pharmacy Benefits

Your Pharmacy benefits under UT SELECT are administered by Medco Health Solutions. Pharmacy Benefits for HMO Blue Texas are administered by Prime Therapeutics. Both Pharmacy benefit plans require a $50 annual deductible per person, per plan year.

Generic Drugs are medications sold under a standard name that by law must have the same active ingredients and are subject to the same U.S. Food and Drug Administration (FDA) standards for quality, strength and purity as their brand name counterpart. Generic drugs usually cost less than brand name drugs.

Preferred Drugs are a list of brand name medications preferred for their clinical effectiveness and opportunities to help contain participant and plan costs. The list of preferred medications is available on each Plan administrator's web site (listed at the end of this section).

Non-Preferred Drugs are brand name medications that are not on the Preferred Drug list because there are effective and less expensive alternatives available. These medications require the highest Copayments.

Copayments for both plans are the same, but each plan may have different medications on its Preferred and Non-Preferred Drug lists. Please compare each plan's Preferred Drug list with any medications you or your dependents are currently taking. The Preferred Drug lists are available online at www.utsystem.edu/egi/providers.asp.

If you choose to purchase a Brand Name Drug when there is a less expensive Generic alternative, you must pay the difference between the cost of the Brand Name drug and the Generic drug plus your Copayment. Sometimes the cost difference is quite large. Here is an example of how you would be reimbursed if you had already met your $50 annual deductible:

The UT SELECT Prescription Drug Plan administered by Medco Health Solutions also offers a small benefit for Out of Network pharmacies. You will pay the full cost of your prescription and send a claim form and your receipt to Medco. Your reimbursement will be based on your total cost, minus the UT discount, the applicable annual deductible and Copayment.

The HMO Blue Texas plan does not include a benefit for Out of Network pharmacies. If you purchase prescriptions from an Out of Network pharmacy, you will be responsible for the full cost of your prescription.

Be sure to check with your Prescription Drug carrier to decide which plan covers your medications at the lowest expense to you.

The following is a comparison of how the 25 most purchased drugs are classified by each Prescription Drug plan.

These classifications are subject to change depending on new drugs approved by the FDA and patent expirations.

NEW - MEDCO FORMULARY FIRST COVERAGE REVIEW

Formulary First Coverage Review is a program that promotes Generic and Preferred brand medications as first line therapy. Therapeutically equivalent Generic or Preferred brands are required before non-preferred drugs unless the physician provides clinical support for the Non-Preferred drug. This program focuses on prescriptions written for the following medications:

• Prevacid
• Aciphex
• Pravachol

Member benefits:

• A targeted pre-notification letter informs you of your choices: a lower cost Generic, Preferred brand, or over-the-counter (OTC) product as treatment options.
• You lower your out-of-pocket cost by using the OTC, Generic or Preferred brand.
• Your physician must approve any change or provide clinical explanation for the non-preferred drug.

UT SELECT

Medications requiring authorization prior to initial prescription (Contact Medco Health to request a Managed Prior Authorization):

• Human Growth Hormones: Protropin, Humatrope, Geref, Genotropin, Norditropin, Nutropin, Saizen, Serostim
• Hormone Agents: Crinone 8%, Lupron, Factrel, Lutrepulse, Synarel
• Immune Globulins: Gamimune, Gammagard, Gammar-IV, Sandoglobulin, Venoglobulin
• Anti-Virals:Acyclovir, Famvir, Valtrex, Zovirax
• Anti-Obesity Agents: Xenical, Meridia, Tenuate & generics, phentermine
• Acne & other dermatologicals: Accutane, Retin-A, Avita

Medications requiring authorization to obtain additional supplies (Contact Medco Health to request a Managed Rx Coverage):

• Onychomycosis Therapy: Sporanox, Lamisil, Diflucan
• Antidepressant Therapy: Wellbutrin SR, Lexapro (new users only)
• Smoking Deterrents: Zyban, Prostep, Nicotrol NS, Habitrol

Medco also offers Health Management programs for certain participants, based on your prescription history. The Health Management programs are included as part of the UT SELECT prescription drug program and are available at no additional cost. The Health Management programs provide educational materials and expert knowledge about many chronic medical conditions including:

• Diabetes
• Hypertension
• Respiratory Disease

HMO Blue Texas’ Pharmacy benefits are administered by Prime Therapeutics. Prime Therapeutics is a national Prescription Benefits Manager (PBM) owned by a number of not-for-profit Blue Cross and Blue Shield plans.

You may read additional information about pharmacy plan features and exclusions in the Medical Plan certificates available from your campus Benefits Office.

UT SELECT AND MEDICARE

In most instances, if you are age 65 or over and are working in a position for at least 20 hours per week, your UT medical plan will be primary, and Medicare Part B, if elected, will be secondary. Medicare Part B may be primary for some Medicare-eligible active employees with certain medical conditions. Consult with your local Social Security Administration office to learn what illnesses qualify for Medicare Part B coverage prior to turning age 65.

If you are retired and also eligible for Medicare, Medicare becomes your primary payer and pays your medical claims first. UT SELECT pays second. If you choose a doctor who accepts Medicare assignment, you will not be responsible for any difference between the billed charge and the Medicare allowed amount.

You become eligible for Medicare at age 65. As an eligible retiree, you have the option of enrolling in Part A and refusing Part B coverage. But if you initially decline Part B, you will have to pay a premium surcharge if you ever re-apply for coverage later. If you decline Medicare Part B, you will be required to pay the portion that Medicare would have paid for Part B-covered items.

If you are under age 65 and eligible for Medicare benefits because of a disability, the same conditions apply as if you were age 65.

In order to assure that your claims are correctly processed, you should contact Blue Cross and Blue Shield of Texas and report your Medicare Health Insurance Claim (HIC) number and the effective dates of Medicare Parts A and B immediately upon enrollment.

If you are enrolled in Medicare and your doctor accepts Medicare assignment:

The doctor may be in or out of the UT SELECT Network UT SELECT will pay 100% of benefits approved but not paid by Medicare (subject to UT SELECT plan limitations)

• No Deductibles
• No Copayments
• No Coinsurance

When you are an inpatient at a facility that accepts Medicare assignment, UT SELECT will pay your Medicare inpatient deductible, and the $100 per day Copay ($500 maximum) will not apply.

If your doctor does not accept Medicare assignment:

• Network and out-of-network benefits apply
• UT SELECT will coordinate with Medicare
• Deductibles may apply
• Copayments may apply
• Coinsurance may apply

This chart shows you exactly how UT SELECT and HMO Blue coordinate benefits with Medicare:

¹All services are subject to HMO Blue referral and authorization requirements.
²The difference between BCBS Allowed and Billed Charges may be paid if that amount is in available COB Savings.
³A Provider who does not participate with Medicare may not bill more than the Medicare Limiting Charge (115% of MC Allowed).

Your Medical Plans and Medicare Part D

On January 1, 2006, Medicare beneficiaries will be eligible for a new Medicare-approved prescription drug benefit. The University of Texas System will continue to offer your current prescription drug benefit even when the new benefit becomes available. Enrollment in Medicare Part D will have a negative financial impact for most UT participants. UT strongly urges you NOT to enroll in the Medicare Part D program.

UT is committed to providing your prescription drug coverage in 2006 and beyond and to helping you make informed choices about your prescription drug benefit. The Medicare prescription drug plans may save you money on your prescription drugs if your annual drug costs are at least the total cost of the monthly premium plus the $250 deductible.

If you choose to enroll in a Medicare plan, you will not be eligible to also have a policy that offers prescription drug coverage. You can keep your UT prescription policy only if you do not enroll in the Medicare Prescription Drug Coverage.

You may find additional information about the Medicare Part D program at www.cms.hhs.gov/medicarereform.