Active Employee Medical Benefits
The City of Fort Worth is pleased to offer you two options for your health insurance coverage. All plans cover the same services, and cost less when you use network providers. The big difference is how you pay for expenses before and after you meet your deductible.
Learn more about the Consumer Choice Health Plan (with Health Savings Account).
How Your Health Insurance Plans Work
All health insurance plans give you the freedom to choose your doctor or health care facility. Your cost for care depends partly on the plan choice you have made, whether the expense is covered by the plan, and whether you choose a Premium Tier 1, or in-network provider.
The Provider Network
The network of doctors and facilities can provide care for you and your covered dependents. The providers in the network provide a wide range of services, from the basic and routine care (general practitioners, pediatricians, internists) to more specialized care (OB/GYN, cardiologists, urologists) to health care facilities (hospitals, physical therapy facilities, skilled nursing facilities).
To find in-network providers in your area, you can use the online provider directory. If your preferred doctor is not in the network, you will need to find a provider who is in the network or pay out of pocket. There is no coverage for providers who are out of network.
Sharing the Cost
You share in the cost of your care by either paying a copayment or meeting a deductible and coinsurance for covered expenses. The amount of your cost will depend on the plan choice you have made.
(Apply to the Basic Plan)
A copayment (copay) is a flat fee for a covered expense. When a copay applies to a given expense, you do not need to meet the annual deductible for that expense. You pay the copay at the time you receive the covered service or supply.
The Annual Deductible
The annual deductible is the amount of covered expenses you must pay each calendar year for certain expenses before the Plan begins to pay benefits. The deductible applies to certain types of expenses, such as:
- Office visits if on the Consumer Choice plan
- Outpatient surgery
- Inpatient hospital care
- MRIs and CT scans
- Outpatient X-ray or lab performed in a hospital
- Durable medical equipment
- Prescription plan
Coinsurance and Out-of-Pocket Maximums
For expenses that do not have a copay, you must meet the annual deductible, then the plan pays a percentage of the expenses and you pay the rest. Your share of the expense is called your coinsurance. For example, if the plan pays 80 percent of an expense, your coinsurance is 20 percent.
Each of our health plans limit the amount of money you will have to pay out of pocket in a plan year. This is your out-of-pocket maximum. It includes the copays, deductible, coinsurance and the deductible and copays for the prescription drug plan. Once you have reached the out-of-pocket maximum, the plan pays 100 percent of your covered expenses for the rest of the plan year.
Your Prescription Drug Benefits
The health plan offers prescription drug benefits through Envision that help you and your family save on both short and long term medication needs.
When you use a network pharmacy, you pay the lowest amount when your doctor prescribes a generic drug, a higher amount for a brand name drug on the plan’s formulary list, and the highest amount for a brand name drug not on the formulary list.
What is the formulary? It is a list of preferred drugs that includes both brand name and generic drugs. It is designed to provide access to quality, affordable outpatient prescription drug benefits.
You pay the most out of your pocket when you use a prescription not on the formulary. To find an Envision network pharmacy or to view the formulary, you can search online or call Envision at 1-800-361-4542.
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