Medical
UT SELECT Benefit Summary Chart (PDF) Pharmacy Benefits UT SELECT and Medicare Notice of Creditable Coverage	Plan Booklets and Related Information: UT SELECT Enrollment Guide (PDF) Find a Provider - Doctors, Hospitals, etc. Contact Benefits Office
Medical Plan Options UT offers UT SELECT, a self-funded medical PPO plan, administered by Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company. Effective September 1st, there is approximately a 6% increase in the monthly premium for UT SELECT plan. Choice of Doctors — Each Time You Need Health Care When you enroll in UT SELECT, you can receive care from any licensed doctor you want. No referrals are required. If you use a Network doctor, you will receive the highest level of benefits, pay less out of pocket, and you usually will not have to file any claims. If you use an Out of Network doctor, you will still be covered, but your out-of-pocket costs for health care services will be higher. Access to One of the Largest Networks in Texas with Worldwide Coverage By choosing UT SELECT, you have access to one of the largest networks of contracting doctors and hospitals in Texas, with more than 45,000 physicians and specialists and over 400 hospitals. If you are traveling outside Texas, there are even more Blue Cross and Blue Shield Network providers from which to choose. More than 85 percent of all doctors and hospitals throughout the United States contract with Blue Cross and Blue Shield plans. Outside of the U.S, you will have access to doctors and hospitals in over 200 countries. With UT SELECT, you have worldwide coverage for both emergency and non-emergency care. International SOS When traveling abroad, coverage is provided for your medical needs through your UT Select program. However, additional services are available through the UT System—wide International SOS program. This is a comprehensive, 24-hour medical response organization that provides international assistance services worldwide through the use of multilingual Alarm Centers on duty 24 hours a day, 365 days a year. International SOS responds to calls for help and advice from students, travelers and expatriates, managing the simplest task such as a doctor referral to the most complex emergency evacuation. Membership is included for no charge when traveling abroad on University business, and is available at a discount when traveling for a personal trip. You may obtain a membership card from your campus travel office. All University related travel abroad that is not booked using one of the University’s contracted travel agencies should be reported to International SOS in advance. This can be done via the UT System SOS portal at http://www.internationalsos.com (use U.T. System Membership # 11BSGC000037 to log on). To find a physician or specialist near you, search online at www.bcbstx.com/ut or contact UT SELECT Customer Service toll free at 1-866-882-2034. Even if you visit an Out of Network doctor, you may still save money. Blue Cross and Blue Shield of Texas contracts with many out-of-network doctors and hospitals. ParPlan providers accept the Blue Cross and Blue Shield of Texas allowable amounts for covered services and cannot bill you more. In most cases ParPlan providers will file claims, too. Look for participating doctors and hospitals for UT SELECT at www.bcbstx.com/ut under ParPlan. Transitional Benefits If you or a covered dependent are being treated for a chronic or ongoing medical condition at the time you are enrolled in UT SELECT and your doctor is not in the UT SELECT PPO network, ongoing care with your current doctor may be requested for up to three months. Some medical conditions that are eligible for transitional benefits include: Pregnancy (if you are in your 3rd trimester on September 1) Cancer Allergy Treatments Organ Transplant Heart Failure Physical Therapy Behavioral Health Care Diabetes Transitional benefits are subject to approval. To request transitional benefits, complete a Transitional BenefitsForm available from your campus Benefits Office or online at www.bcbstx.com/ut. Instructions for submitting the request to Blue Cross and Blue Shield of Texas are on the form. If the transitional care request is approved, you or your covered dependent may continue to see the Out of Network doctor and receive the Network level of benefits from the UT SELECT plan for up to three months. If the transitional care request is denied, you may still continue to see your current doctor, but benefits will be paid at the Out of Network level. If your doctor under your previous plan is in the UT SELECT PPO Network, you do not have to complete a Transitional Benefits Form. Note: Most HMO Blue doctors are also in the UT SELECT PPO network. Disease Management Programs - Helping You Achieve a Healthier Life Sometimes managing your health requires more than doctor visits, lab tests and prescriptions. Blue Care Connection from Blue Cross and Blue Shield of Texas is an umbrella of programs that helps you achieve higher levels of wellness. Through outreach, educational resources and health advocacy, Blue Care Connection guides you through the often-complex health care system so you can focus on what matters most — getting healthy and staying well. Blue Care Connection programs assist UT SELECT plan participants living with current serious medical conditions, as well as those considered "at risk." If you, or a covered dependent, are considered "at risk," the Blue Care Connection programs are uniquely designed to detect health care needs early. Early detection allows Blue Cross and Blue Shield of Texas to provide appropriate outreach and meaningful intervention to help prevent future medical complications. Blue Care Connection programs are available at no additional cost and include: Blue Care Advisors – Experienced and knowledgeable Registered Nurses, Licensed Professional Counselors and Licensed Masters-Level Social Workers with your best health in mind. Advisors will work with you and your physician to educate, facilitate and monitor your treatment plan. 24/7 NurseLine – Around the clock access through a toll-free number to experienced registered nurses who understand and can help with your health care concerns. To take advantage of this free service and to talk to a nurse, call toll-free: 1-888-315-9473, anytime 24 hours a day, 7 days a week. Special Beginnings® – A maternity program that offers on-going contact with obstetric nurses who provide prenatal risk assessment education and can coordinate care with your physician. Blue Cross and Blue Shield of Texas offers a $50 reward card from Target for women who enroll in their first trimester and complete the Special Beginnings program through six weeks after delivery. Call 1-800-462-3275 to enroll or ask questions about the program. Condition Management – Voluntary, health improvement programs that can help members with cancer, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, asthma, diabetes, metabolic syndrome (high cholesterol, high blood pressure and obesity) and low back pain. Care Management – Focuses on traditional elements of medical care management with targeted outreach if you are an “at-risk” member.Focuses on traditional elements of medical care management with targeted outreach if you are an “at-risk” member. Case Management – Assists if you are a higher-risk plan participant coping with a complex or catastrophic condition. LifeMasters Disease Management As part of UT SELECT, Blue Cross and Blue Shield of Texas provides a disease management program for enrollees with certain conditions through the LifeMasters program. If your UT SELECT claims records indicate that you have such a condition, LifeMasters staff may contact you directly via telephone to inform you about the disease management program and determine if you are interested in participating. These contacts are monitored and controlled by Blue Cross Blue Shield of Texas as part of UT SELECT’s health care operations. If you decline, LifeMasters will not contact you again. If you decide to participate, the LifeMasters’ staff will provide you with information about participating. LifeMasters’ Blue Cross Blue Shield and UT SELECT keeps all LifeMasters contact and program information confidential and private. Enroll Today To enroll in any Blue Care Connection program, or ask questions about the program, please call toll-free at 1-800-462-3275. New! Effective September 1, 2007—More Blue Care Connection Programs In addition to the Blue Care Connection programs already listed, some new programs will be available to UT SELECT plan participants for the 2007-2008 plan year effective September 1. Blue Care Advisors Blue Care Advisors are a multi-disciplinary team composed of Registered Nurses, Licensed Professional Counselors and Licensed Masters-Level Social Workers. Blue Care Advisors reach out to at-risk plan participants, providing early chronic disease prevention in hopes of achieving overall improved health. Blue Care Advisors: Simplify the coordination of your health care benefits, Educate and empower you to make informed choices about your health care, Support wellness by aiding your understanding of preventive care guidelines, personal risk assessments and preventive screenings, Support behavior modification and readiness to change with techniques that promote a healthy lifestyle, Champion your care when assistance is needed, and Provide lifestyle coaching through the Obesity/Weight Management Program (as needed) Personal Health Manager With Personal Health Manager, the support and resources you need to manage your health online will be just a click away. By logging onto Blue Access® for Members and clicking on Personal Health Manager you can: Earn Blue PointsSM every time you use the health and wellness features in the For Your Health section. Receive up to 1,000 points a week when you set up and track the progress of an exercise or meal program, read and rate health and wellness related articles, or e-mail your health-related questions to licensed professionals. Complete a health risk assessment to evaluate your health status. Request fitness and weight loss advice with Ask A Dietitian. Receive help on managing stress, workplace conflicts or other issues with Ask A Life Coach. Ask registered nurses health-related questions online with the Ask A Nurse feature. Receive targeted wellness information via e-mail to help manage specific medical conditions, including alerts for screening tests, and set up reminders for medical appointments and medication refills. Access wellness tracking tools, videos and interactive tutorials. Get information on exercise, nutrition and lifestyle issues in the For Your Health section. Behavior Modification Obesity/Weight Management Program UT SELECT coverage will also feature new lifestyle management programs, comprised of Licensed Masters Level Social Workers and Licensed Professional Counselors who promote wellness through a holistic approach of behavioral coaching, clinical coaching, education and condition management. Regardless of your personal health status, every UT SELECT plan participant can take advantage of important health and wellness resources from Blue Cross and Blue Shield of Texas. Blue Access® for Members - Information is a Powerful Tool Go to www.bcbstx.com/ut, log onto Blue Access for Members, and: Check the status of a claim and your claims history Confirm who in your family is covered under your plan View and print an Explanation of Benefits (EOB) for a claim Locate a doctor or hospital in the Network Select the option to stop receiving EOBs in the mail Sign up to receive claim status e-mail alerts Request email notification of finalized claims Request a new or replacement ID card or print a temporary ID card Take a Health Risk Assessment To register for Blue Access® for Members, you will need your group and identification numbers from your UT SELECT ID card. You will be asked to create a user ID and password for immediate and secure access to your personal information. Health Risk Assessment Learn about your health status and risks by completing a confidential Health Risk Assessment (HRA) available through Blue Access® for Members. By completing the HRA, you can receive recommendations for improving your health and share the information with your physicians. The HRA focuses on four key areas—stress, sleep, fitness, and nutrition. You can take the HRA multiple times. Information is available about emotional well-being, in addition to physical well-being. Based on your responses, you can receive additional information about programs and services. The HRA includes an easy-to-use online questionnaire. Upon completion, you can receive an in-depth personal report that helps you understand your current health status and risks, along with specific suggestions on how to make positive and lasting changes. Results can help determine if you need intervention before a more serious condition may develop. Take the HRA today! Be assured that your information is kept confidential and will not be released to your employer. Other Online Resources for Health Care Information Hospital Comparison Tool When your physician has recommended a surgical treatment, you can easily find and review the outcome history of procedures previously performed at hospitals. You can review a hospital’s performance based on factors such as: Mortality Length of stay Complications Number of procedures performed Cost To review hospital outcome data, log onto Blue Access® for Members, click on the My Health section and select Compare Hospitals. Treatment Cost Advisor Through the Treatment Cost Advisor* tool, you can find the typical cost of a health care procedure from a list of common medical conditions. You simply need to enter information, such as age, gender and state or ZIP code to help determine a cost estimate for a specified medical procedure. To get started, log onto Blue Access® for Members, click on the My Health section and select Treatment Cost Advisor. * All information is intended for your general use only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for specific health issues and consult your physician before taking any action on your health conditions. Use of this online service is subject to Terms and Conditions. New! Blue ExtrasSM Available now to all UT SELECT Plan Participants Blue ExtrasSM arranges for UT SELECT plan participants and covered dependents to have access to discounts on a variety of alternative and complementary health care services and products. Jenny Craig Membership Discounts Good health requires more than good intentions – especially when it comes to weight management and fitness! Blue Cross and Blue Shield of Texas now offers you and covered dependents a discounted joining fee to Jenny Craig. The Jenny Craig program balances food, body and mind. Together with one-on-one support, Jenny Craig consultants design a personalized program that fits your lifestyle. Here are some highlights of the Jenny Craig discounted program: TuneUp — FREE 30-day Trial program*   Normally offered at a charge of $6 per week, this program will be free of charge for 30 days for UT SELECT plan participants, plus the cost of food. OnTrack — 50% off the 6-month (Gold) or 1-year (Platinum) programs*   UT SELECT plan participants receive a 50% discount off the Gold program’s normal full price of $199, plus the cost of food. Plan participants receive a 50% discount off the Platinum program’s normal full price of $399, plus the cost of food. There is a 10% discount on food purchases while maintaining desired weight (within 5 pounds). Jenny Rewards — 20% off the 1-year program* UT SELECT plan participants receive a 20 % discount off the normal full price of $399 and also receive weekly discounts** on food purchases as follows: 10% off food purchase for Rewards Visits 1-10 20% off food purchase for Rewards Visits 11-20 30% off food purchase for Rewards Visits 21+ 35% off food purchase (after week 20) while maintaining desired weight (within 5 pounds) *Plus the cost of food. Discounts apply to membership fee only. Offer good at participating Centers only. Subject to change. ** Based on active participation only. To register for the Jenny Craig discounts, log onto Blue Access® for Members through www.bcbstx.com/ut and click on the My Coverage tab, then Your Discounts, then the Jenny Craig logo. Fill out the registration form and click SUBMIT. Once you submit, your special offer coupon will appear on the screen. Print the coupon and bring it with your UT SELECT ID card to your free consultation. To find the nearest Jenny Craig Center, log onto www.jennycraig.com or call (800) 597-Jenny (5366). Be sure to identify yourself as a Blue Cross and Blue Shield of Texas member and UT SELECT plan participant. Curves Membership Discounts A regular exercise program is vital to achieving and maintaining a healthy weight. Curves is the first fitness and weight loss facility to target women and provide them with affordable, one-stop exercise and nutritional information. Curves offers a 30-minute workout that combines strength training and sustained cardiovascular activity through safe and effective resistance equipment. Curves has made exercise available to more than four million women, many of whom are in the gym for the first time. UT SELECT plan participants and covered dependents can join Curves for a special $49* joining fee. To take advantage of this discount, present your UT SELECT ID card to any Curves location**. For more information, you can log onto Blue Access® for Members at www.bcbstx.com/ut, click on the My Coverage tab, then click Your Discounts. You may also visit www.curves.com or call (800) CURVES-30. * Additional regular monthly fee applies. **Franchisee participation and discount may vary. TruHearing Blue Cross and Blue Shield of Texas has arranged a discount program through TruHearing* that offers digital hearing aids at a reduced price. This program is available to you and your covered dependents, as well as your parents and grandparents who are not enrolled in a Blue Cross and Blue Shield of Texas plan. With the digital hearing aids offered through TruHearing you simply choose one of 3 price levels available, and then select the style that you prefer within that level. Call TruHearing at the number below to discuss your options and to find the nearest provider. Basic Medallion Ultra Your Price $995 each Your Price $1,495 each Your Price $1,995 each Regular Price $1,595 each Regular Price $3,595 each Regular Price $4,755 each 100% digital, plus: 2 channels 2 memories Microphone Noise Reduction Everything in Basic, plus: 7 channels 3 memories Sensitive Voice Processing Adaptive Feedback Detection Everything in Medallion, plus: 14 channels 6 compression areas Adaptive Noise Reduction Speech Preservation Much more… The TruHearing program includes: Free hearing screening 45-day money back guarantee 2-year warranty 12 months, no interest financing available upon approved credit *The relationship between Blue Cross and Blue Shield of Texas and TruHearing is that of independent contractors. This is a discount program only. However, some of the services offered may be covered under your health plan. Use of this program does not affect your premium, nor do costs of the program services and products count toward calendar year or lifetime maximums and/or plan deductibles. To learn more about the TruHearing discount program, for location information or to schedule a hearing test call toll free (877) 882-2020. Operators available 8 a.m. – 8 p.m. (CT) Monday – Friday or visit www.TruHearing.com. You may read additional information about plan features and exclusions in the Medical Plan guides available from your campus Benefits Office or online at www.utsystem.edu/benefits.
UT SELECT PPO (medical coverage) (Blue Cross and Blue Shield of Texas) www.bcbstx.com/ut (866) 882-2034 8:00 AM - 5:00PM CST
Pharmacy Benefits Your Pharmacy benefits under UT SELECT are administered by Medco Health Solutions (Medco) and requires a $50 annual deductible per person, per plan year. Your prescription drug program offers three different benefit levels based on the drug category. As described below, My Rx Choices will help you make the most of your prescription benefits. 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 the Medco website (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. UT SELECT Pharmacy Benefits Annual Deductible $50/person/year (Deductible does not apply to medical plan deductible) Access Options Generic Drug Copayment Preferred Drug Copayment Non-Preferred Drug Copayment Retail Network Pharmacy: Up to a 30-day supply*. Refills allowed as prescribed. (Good option for new prescriptions) $10 $30 $45 Home Delivery Pharmacy: Up to a 90-day supply*. Refills allowed as prescribed (Best option for maintenance medication) $20 $75 $112.50 *Copayments will not be pro-rated if you receive less than a 90-day supply, unless your home delivery order meets the requirements of the MAXX program. 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. This difference does NOT count toward your $50 annual deductible per person per plan year. Sometimes the cost difference is quite large. Below is an example of how you would be reimbursed if you had already met your $50 annual deductible:
Cost of Brand Name Drug $150 Less cost of Generic Equivalent -$55 Plus Cost of Generic Copayment +$20 Your Payment $115
The UT SELECT Prescription Drug Plan administered by Medco 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 following is a list of how the 25 most purchased drugs are classified by Medco.

DRUG NAME UT SELECT Lipitor Preferred Nexium Preferred Azithromycin Generic Zyrtec Preferred Toprol XL Preferred Norvasc Non-Preferred Singulair Preferred Simvastatin Generic Fexofenadine HCL Generic Sertraline HCL Generic Lexapro Non-Preferred Fluticasone Propionate Generic Ambien Preferred Levaquin Preferred Vytorin Preferred Fosamax Preferred Effexor XR Non-Preferred Advair Diskus Preferred Omeprazole Generic Wellbutrin XL Preferred Crestor Preferred Nasonex Preferred Lotrel Preferred Altace Preferred Diovan Preferred

Preferred/Non-Preferred classifications are subject to change during quarterly pharmaceutical review. MEDCO Preferred Drug Step Therapy Program Preferred Drug Step Therapy 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 Zegerid Protonix Prilosec 40mg Ambien CR Lunesta Rozerem Sonata Member Benefits of the Step Therapy Program: You lower your out-of-pocket cost by using the over-the-counter, Generic or Preferred brand. Your physician must approve any change or provide clinical explanation for the Non-Preferred drug. Medications requiring authorization prior to initial prescription (Contact Medco Health to request a Traditional 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-Psoriasis: Raptiva Anti-Obesity Agents: Xenical, Meridia, Tenuate & generics, phentermine Asthma: Xoliar Respiratory Syncytial Virus (RSV) therapy: Synagis, RespiGam Cancer Therapy: Iressa, Gleevec, Tarceva Irritable Bowel Syndrome (IBS): Lotronex Acromegaly: Somavert Interferons: Actimmune, Infergen, Roferon, Intron, Intron-A, Alferon, Rebetol, Rebetron, PEG-Intron, Pegasys Erythroid Stimulants: Epogen, Procrit, Aranesp Multiple Sclerosis Agents: Betaseron, Avonex, Rebif, Copaxone Myeloid Stimulants: Neupogen, Leukine, Neulasta Platelet Growth Factor: Neumega Immunomodulatory Agents: Thalomid Acne & other dermatologicals: Accutane, Retin-A, Avita for ages 36 and over Medications requiring authorization to obtain additional supplies (Contact Medco Health to request a Smart Prior Authorization): Onychomycosis Therapy: Sporanox, Lamisil, Diflucan, fluconazole Anti-Virals: Acyclovir, Famvir, Valtrex, Zovirax Pain Management: Actiq, Fentora Rheumatoid Arthritis: Humira, Enbrel Hypnotic Agents: Ambien, Ambien CR, Lunesta, Rozerem, Sonatal Medications requiring authorization based on drug history (Contact Medco Health to see if authorization is required): Pain Management: Actiq, Fentora Antidepressant Therapy: Wellbutrin SR, Bupropion SR Rheumatoid Arthritis: Enbrel, Humira, Kineret, Arava, Remicade Dermatological Agent: Elidel, Protopic 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 Plan 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 New! Effective September 1, 2007— MAXX Program The MAXX program pro-rates your mail copay when a prescription is sent to Medco and written for less than UT SELECT’s maximum days/supply. Often times, prescriptions are received by Medco and written for less than the mail maximum days/supply. Patients are surprised when they receive less than the plan maximum allowed days/supply of a medication and are charged the 90 day/supply copay. Certain narcotic and other medications are not eligible for the MAXX program. The MAXX program will pro-rate the copay, one time per patient, per drug when the days supply is less than the plan maximum. A letter and a pre-populated fax form (with the medication and correct days/supply) will be included in the prescription package to ensure that the next prescription is written correctly. My Rx Choices An industry-leading prescription savings program, offered as an enhancement to your benefit plan allowing you to: View a single presentation of medications with potential savings Comparison-shop for available lower-cost alternatives “With-a-click” option to have Medco contact physicians on members’ behalf to request approval for equivalent conversions received through mail Review options with your doctor and request prescriptions for lower-cost alternatives Accessed via the web (www.medcohealth.com) or through the toll-free service line (1-800-818-0155), My Rx Choices features include: Personal assessment of cost-saving opportunities Best-value alternatives based upon greatest cost savings to you presented in order from highest value to you The most accurate, actionable drug compare pricing information available in the industry today Brand-to-generic and retail-to-mail compare options available You may read additional information about pharmacy plan features and exclusions in the Medical Plan certificates available from your campus Benefits Office or online at www.utsystem.edu/benefits.

UT SELECT PPO Pharmacy Benefits (Medco Health Solutions, Inc.) www.medcohealth.com (800) 818-0155 24 hours a day

UT SELECT and Medicare When you or your covered dependent(s) become eligible for Medicare, you and your Medicare-eligible dependents should enroll in Part A (typically in-patient coverage) and Part B coverage (typically office visits and doctor fees). The University of Texas System urges all retired employees and dependents to enroll in Medicare Parts A and B when they become eligible at age 65 or earlier if they are eligible due to a disability. This is because, if you are a retired employee or will soon become a retired employee or the dependent of a retired employee and are eligible for Medicare, you must have Medicare Parts A and B to receive the maximum benefits available from the UT SELECT plan. It is your responsibility to inform your campus Benefits Office if your covered dependents are Medicare-eligible. In most instances, if you are eligible for Medicare and are working in a position for at least 20 hours per week, your UT SELECT plan will be primary, and Medicare will be secondary. Medicare 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 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. If you decline Part B, you will have to pay a higher premium if you ever re-apply for Medicare coverage. In addition, without Medicare Part B, you become responsible for paying any share of your and your Medicare-eligible dependents’ medical claims that Medicare Part B would have covered. As a retiree, if you or your Medicare-eligible dependent have declined Medicare Part B and fail to re-apply, you will be required to pay the portion that Medicare Part B would have paid as primary insurer for Part B-covered items for yourself and any Medicare-eligible dependents. In order to ensure that claims are correctly processed, you should contact Blue Cross and Blue Shield of Texas and report your or your dependent’s Medicare Health Insurance Claim (HIC) number and the effective dates of Medicare Parts A and B immediately upon enrollment. If you or your dependents 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 or your dependents are an inpatient at a facility that accepts Medicare assignment, UT SELECT will pay the 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 coordinates benefits with Medicare. All benefits are subject to plan limitations:

Provider Accepts Medicare Assignment BCBSTX In-Network Provider Service Covered by Medicare Medicare Pays UT SELECT Pays (Subject to plan limitations) UT SELECT Member Pays Y Y Y 80% MC Allowed 20% MC Allowed 0 Y N Y 80% MC Allowed 20% MC Allowed 0 Y Y N 0 80% of BCBS Allowed after $250 Deductible or 100% after Copay, whichever is applicable 20% of BCBS Allowed after $250 Deductible or 100% after Copay, whichever is applicable Y N N 0 60% of BCBS Allowed after $500 Deductible1 $500 Deductible + 40% of BCBS Allowed + Difference between Billed Charge and BCBSTX Allowed N Y Y 80% MC Limiting Charge2 20% MC Limiting Charge after $250 Deductible $250 Deductible N N Y 80% MC Limiting Charge 20% MC Limiting Charge after $500 Deductible $500 Deductible N Y N 0 80% of BCBS Allowed after $250 Deductible or 100% after Copay, whichever is applicable 20% of BCBS Allowed after $250 Deductible or 100% after Copay, whichever is applicable N N N 0 60% of BCBS Allowed AFter $500 Deductible $500 Deductible + 40% of BCBS Allowed + Difference between Billed Charge and BCBSTX Allowed

1The difference between BCBS Allowed and Billed Charges may be paid if that amount is in available COB Savings. 2A 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 became eligible for a new Medicare-approved prescription drug benefit – Medicare Part D. The University of Texas System continues to offer your current prescription drug benefit, and 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 now and in the future and to helping you make informed choices about your prescription drug benefit. For a relatively small amount of very low-income retirees, enrolling in Medicare Part D may save money if the retiree also qualifies for a “low income subsidy” provided as part of the Medicaid Part D Program. For more information about the low income subsidy visit www.socialsecurity.gov or call 1-800-772-1213. If you choose to enroll in a Medicare prescription drug plan, you will not be able to use the UT SELECT drug coverage for the same prescription. You may find additional information about the Medicare Part D program at www.cms.hhs.gov/medicarereform.