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					Benefits Booklet
Effective
September 1, 2004
ActiveCare 1, 2 and 3
Health Plans
Table of Contents




   Welcome                                                                                      Plan Provisions
   Meeting Your Health Care Needs . . . . . . . . . . . . . . . . . . . . . . . .1              Employee Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
   Important Phone Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1           Eligible Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
                                                                                                Making Changes/Special Enrollment Events . . . . . . . . . . . . . . .27
   Your TRS-ActiveCare Benefits                                                                 Loss of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
   ActiveCare 1 Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . .2             Court-Ordered Dependent Children . . . . . . . . . . . . . . . . . . . . .28
   ActiveCare 2 Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . .4             Request for Exceptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
   ActiveCare 3 Benefits Summary . . . . . . . . . . . . . . . . . . . . . . . . .6             Effective Date of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
                                                                                                When Coverage Ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
   How Your Medical Plan Works                                                                  Continuation of TRS-ActiveCare Coverage (COBRA) . . . . . . . . . .34
   Network vs. Non-Network Providers . . . . . . . . . . . . . . . . . . . . . .8               How to File a Medical Claim . . . . . . . . . . . . . . . . . . . . . . . . . . .36
   Preauthorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . .9           Request for Reconsideration of a Claim Determination . . . . . . .37
   How to Preauthorize . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9       Subrogation, Reimbursement and Third Party Recovery Provision . . .38
   Accessing the BlueCard Program for Health Care Outside Texas 10                              Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
   What the Medical Plan Covers . . . . . . . . . . . . . . . . . . . . . . . . .11
   Transitional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19    Online Resources
   What the Medical Plan Does Not Cover . . . . . . . . . . . . . . . . . .20                   Web Site Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
                                                                                                Blue Access for Members . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
   How Your Prescription Drug Plan Works
   ActiveCare 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22   Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
   ActiveCare 2 and ActiveCare 3 . . . . . . . . . . . . . . . . . . . . . . . . .22
   Prescription Drug Formulary . . . . . . . . . . . . . . . . . . . . . . . . . .22            Notices
   The Generic Drug Advantage . . . . . . . . . . . . . . . . . . . . . . . . . .24             Health Insurance Portability and Accountability Act . . . . . . . . . .45
   Exclusions from Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . .24                Notice of Privacy Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
   Prescription Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25       Women's Health and Cancer Notice . . . . . . . . . . . . . . . . . . . . .49
   Special Care Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25          Continuation Coverage Rights Under COBRA . . . . . . . . . . . . . . .50
   How to Get Your Prescriptions Filled . . . . . . . . . . . . . . . . . . . . .25             Sample ID Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52




                                                                         TRS-ActiveCare is administered by Blue Cross and Blue Shield of Texas, a Division
                                                                         of Health Care Service Corporation, a Mutual Legal Reserve Company, an
                                                                         Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross
                                                                         and Blue Shield of Texas provides claims payment services only and does not
                                                                         assume any financial risk or obligation with respect to claims. Prescription drug
                                                                         benefits are administered by Medco Health Solutions, Inc. (Medco).




                                                                                                                                                        8709.527-804
Welcome                                 TRS laws and regulations and this Benefits Booklet are TRS-ActiveCare's official statement about the
                                        TRS-ActiveCare program and supersede any other statement or representation made concerning
                                        TRS-ActiveCare, regardless of the source of that statement or representation. To the extent that any
                                        information in this Benefits Booklet is not consistent with or contradicts TRS laws and rules, the TRS laws
                                        and rules control. TRS reserves the right to amend the Benefits Booklet at any time.




Meeting Your Health Care Needs
                                                                     Read this first…
TRS-ActiveCare assists you and your family in case
of illness or injury. The plan covers many health care               • TRS-ActiveCare is a self-funded health coverage plan, not an insurance policy.
                                                                       That means the premiums collected must cover the cost of benefits utilized.
needs, including preventive care and physician office
                                                                       It’s your money...spend it wisely.
visits, inpatient and outpatient services, behavioral health,
                                                                     •This plan does not pay for every medical or drug expense you may incur. You
prescription drugs, and more.
                                                                      may be responsible for a share of the cost, so be an informed consumer. Read
This booklet is a guide to your TRS-ActiveCare health                 this booklet carefully. Refer to the Web site or call Customer Service with
                                                                      questions before you make health care decisions.
benefits. It includes definitions of terms you should know
and detailed information about your TRS-ActiveCare plan.             • You must complete and submit an enrollment form within the appropriate time
                                                                       period to add coverage for newborns and other new dependents, even if you
Tips on how to use the plan effectively, answers to
                                                                       already have family or children coverage.
frequently asked questions, and a comprehensive table of
contents to help you locate information you need are also            • Thousands of prescription drugs are covered by TRS-ActiveCare, but some
                                                                      exclusions and limitations may apply under the TRS-ActiveCare plan.
included. If you have questions, call Customer Service at
                                                                      Check the Web site or call Customer Service for specific drug coverage
1-866-355-5999, refer to the Web site or contact your                 information.
Benefits Administrator.
                                                                     • Some drug therapies may require a conversation between your doctor and
                                                                       Medco, the pharmacy benefit manager for TRS-ActiveCare. You can check on
                                                                       many of these drugs on the TRS-ActiveCare Web site under “Prescription
 Important Phone Numbers                                               Management Programs” or call Customer Service.

 Customer Service                                                    • If you use a non-network provider, regardless of the circumstances, you
 1-866-355-5999                                                        may have to pay more than the usual deductible and coinsurance amounts.
 8 a.m. - 8 p.m. (Central Time) Monday through Friday                • Many areas are served by ambulance services that do not contract with
                                                                       any provider networks. These services often charge more than
 Preauthorization                                                      TRS-ActiveCare will pay, and you will be responsible for charges exceeding
 1-800-441-9188                                                        the Blue Cross and Blue Shield of Texas allowable amount.
 6 a.m. - 6 p.m. (Central Time) Monday through Friday
                                                                     • Do not depend on others to manage your coverage. You are responsible
 INROADS® Behavioral Health                                            for the decisions you make and for complying with the TRS-ActiveCare plan
 1-800-528-7264                                                        rules. If you have questions, refer to the Web site or call Customer Service.
 8 a.m. - 5 p.m. (Central Time) Monday through Friday
                                                                     • Appeals are handled by the TRS-ActiveCare Grievance Administrator, not the
                                                                       Texas Department of Insurance. Remember, TRS-ActiveCare is not an
 BlueCard PPO Access
                                                                       insurance policy. See page 37 for more information on appeals.
 1-800-810-BLUE (2583) 24 hours, seven days a week
                                                                     • Don’t assume anything. Refer to this booklet or call Customer Service if you
 Web Site                                                             have any questions about your coverage.
 www.trs.state.tx.us/trs-activecare




                                              www.trs.state.tx.us/trs-activecare                                                                        1
    Your TRS-ActiveCare Benefits
    ActiveCare 1 Benefits Summary                                                               differences between network and non-network providers. When you use a network
                                                                                                physician, there is a $15 office visit copayment for preventive care only, up to the
    The benefits summary that follows shows what the plan pays for covered services             $500 plan year maximum per individual; remaining charges will be subject to
    and supplies, with a comparison of network and non-network benefits. The section            deductible and coinsurance. For covered services other than preventive care, the
    on How Your Medical Plan Works found on page 8 explains in more detail the                  plan will pay benefits after you meet the deductible.




                       General Provisions                                                Network                                                 Non-Network
      Deductible (per plan year)
        Individual                                                                                                     $1,000
        Family                                                                                                         $3,000
      Out-of-Pocket Maximum (per plan year; does not
      include deductible or copays)
        Individual                                                                                                     $2,000
        Family                                                                                                         $6,000
      Lifetime maximum benefit                                                                                         Unlimited
      Doctor and Lab Services
      Doctor office visits
                                                                       After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      (includes injections, diagnostic X-rays and lab tests)
      Allergy injections                                               After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Contraceptive devices                                            After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Office surgery                                                   After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Outpatient surgery                                               After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Maternity care (doctor charges only; see
                                                                       After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Hospital/Facility Services for inpatient charges)
      Inpatient doctor visits                                          After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Preventive Care
      When using network physicians, benefits are paid at 100% after copay up to the first $500 per individual, per plan year; remaining charges will be subject to deductible and
      coinsurance. (Copays apply to any covered services provided in the doctor’s office.) Preventive care visits–network or non-network–are limited to one physical exam per plan
      year for age two and over; one OB/GYN well-woman exam per plan year; and one routine mammogram per plan year.
      Office visit (including lab, X-rays, immunizations)                              $15 copay                                After deductible, plan pays 60%; you pay 40%
      Routine eye exam (one per plan year)                                             $15 copay                                After deductible, plan pays 60%; you pay 40%
      Hearing exams                                                                    $15 copay                                After deductible, plan pays 60%; you pay 40%
      Lab and X-ray (outside the doctor's office)                                     Plan pays 100%                            After deductible, plan pays 60%; you pay 40%
      Immunizations (outside the doctor's office)                                     Plan pays 100%                            After deductible, plan pays 60%; you pay 40%
      Routine mammograms (outside the doctor's office.)                               Plan pays 100%                            After deductible, plan pays 60%; you pay 40%
      Hospital/Facility Services
                                                                                                             Preauthorization required
      Inpatient hospital (semi-private room and board or
      intensive care unit)                                             After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%

      Other inpatient charges (including surgery)                      After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Outpatient hospital/facilities                                   After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Emergency room care within 48 hours of accident or
                                                                                                   After deductible, plan pays 80%; you pay 20%
      medical emergency
      Emergency room care for all other conditions                     After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      Extended Care Services (preauthorization required for all services)
      Skilled nursing facility ($10,000 plan year maximum;
                                                                       After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      up to $7,000 may be non-network)
      Home health care ($10,000 plan year maximum; up to
                                                                       After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      $7,000 may be non-network)
      Hospice ($20,000 lifetime maximum; up to $14,000
                                                                       After deductible, plan pays 80%; you pay 20%             After deductible, plan pays 60%; you pay 40%
      may be non-network)



2                                                   To l l - f r e e   Customer         Service:         1-866-355-5999
Payment for non-network services is limited to the allowable amount, and you are          Medco By Mail. You will be required to pay in full when you receive your
responsible for any balance billed by the provider, except for emergency care services    medication and submit a claim form to Blue Cross and Blue Shield of Texas.
(see page 13).                                                                            The plan will treat your prescription drug expense as a medical claim and will pay
                                                                                          benefits after you meet the deductible.
Network retail pharmacies will accept your TRS-ActiveCare ID card and charge you
the negotiated Medco discounted price for up to a 30-day supply of your prescription.
You may also obtain up to a 90-day supply of your prescription through




                       General Provisions                                           Network                                                Non-Network
  Other Medical Services
  Physical therapy
  • Office visit                                                After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  • All other services                                          After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Chiropractic care (up to $1,500 per plan year)
  • Office visit                                                After deductible, plan pays 80%; you pay 20%            After deductible, plan pays 60%; you pay 40%
  • All other services                                          After deductible, plan pays 80%; you pay 20%            After deductible, plan pays 60%; you pay 40%
                                                                                                      Preauthorization required
  Home Infusion Therapy
                                                                After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Hearing aids (up to $1,000 per 36-month period)                                             After deductible, plan pays 80%; you pay 20%
  Durable medical equipment                                     After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Prosthetics                                                   After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
                                                                 After deductible, plan pays 80% of the allowable amount; you pay the remaining 20% plus any charges
  Ambulance services (ground or air)
                                                                                      exceeding the allowable amount billed by non-network providers
  Behavioral Health (Mental Health and Chemical Dependency)
  Mental Health (preauthorization required for all services)
  Inpatient facility (up to 30 days per plan year)              After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Inpatient physician charges
                                                                After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  (up to 30 visits per plan year)
  Outpatient/office visit
  (up to 30 visits per plan year; non-network                   After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  limited to $60 allowable per visit)
  Chemical Dependency (preauthorization required for all services) (maximum of two separate series per lifetime)
  Inpatient facility                                            After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Inpatient physician charges                                   After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Outpatient                                                    After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Office visit                                                  After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Serious Mental Illness (preauthorization required for all services)
  Inpatient facility (up to 45 days per plan year)              After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Inpatient physician (up to 45 visits per plan year)           After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Outpatient                                                    After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Office visit (up to 60 visits per plan year)                  After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Prescription Drugs
  Retail Short-Term (up to a 30-day supply)                    You pay 100% of the discounted cost at the time of      You pay 100% of the full cost at the time of purchase,
  • Generic                                                   purchase, and after the deductible is met, you will be   and after the deductible is met, you will be reimbursed
  • Preferred brand                                         reimbursed 80% by Blue Cross and Blue Shield of Texas           80% by Blue Cross and Blue Shield of Texas
  • Non-preferred brand                                              (Must submit claim to be reimbursed)                      (Must submit claim to be reimbursed)

  Retail Maintenance (up to a 30-day supply)                   You pay 100% of the discounted cost at the time of      You pay 100% of the full cost at the time of purchase,
  • Generic                                                   purchase, and after the deductible is met, you will be   and after the deductible is met, you will be reimbursed
  • Preferred brand                                         reimbursed 80% by Blue Cross and Blue Shield of Texas           80% by Blue Cross and Blue Shield of Texas
  • Non-preferred brand                                              (Must submit claim to be reimbursed)                       (Must submit claim to be reimbursed)

  Mail Order
                                                               You pay 100% of the discounted cost at the time of
  (up to a 90-day supply)
                                                              purchase, and after the deductible is met, you will be
  • Generic                                                                                                                                     N/A
                                                            reimbursed 80% by Blue Cross and Blue Shield of Texas
  • Preferred brand
                                                                     (Must submit claim to be reimbursed)
  • Non-preferred brand



                                                        www.trs.state.tx.us/trs-activecare                                                                                       3
    ActiveCare 2 Benefits Summary
    The benefits summary that follows shows what the plan pays for covered services                     OB/GYN or pediatrician. There is also a $25 primary care copayment ($35 for a
    and supplies, with a comparison of network and non-network benefits. The section                    specialist) for preventive care, up to the $500 plan year maximum per individual; any
    on How Your Medical Plan Works found on page 8 explains in more detail the                          remaining charges will be subject to deductible and coinsurance. For covered
    differences between network and non-network providers. When you use a network                       services other than preventive care, the plan will begin to pay benefits after you
    physician, you pay $25 for a primary care office visit and $35 for an office visit with             meet the deductible.
    a specialist. A specialist is any physician other than a family practitioner, internist,




                        General Provisions                                                     Network                                                     Non-Network
       Deductible (per plan year)
           Individual                                                                                                               $500
           Family                                                                                                                  $1,500
       Out-of-Pocket Maximum (per plan year; does not
       include deductible or copays)
          Individual                                                                                                                $2,000
          Family                                                                                                                    $6,000
       Lifetime maximum benefit                                                                                                    Unlimited
       Doctor and Lab Services
       Doctor office visits (includes injections, diagnostic X-rays                   $25 copay for primary/
                                                                                                                                            After deductible, plan pays 60%; you pay 40%
       and lab tests when performed during an office visit)                           $35 copay for specialist
       Diagnostic X-rays and lab tests
                                                                        After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
       (when no office visit is billed)
       Allergy injections (when no office visit is billed)              After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
       Contraceptive devices (when no office visit is billed)           After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
       Office surgery                                                   After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
       Outpatient surgery                                               After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
                                                                         $25 copay for primary/$35 copay for specialist
       Maternity care (doctor charges only; see
                                                                        (for initial visit only; for delivery, after deductible,            After deductible, plan pays 60%; you pay 40%
       Hospital/Facility Services for inpatient charges)
                                                                                 plan pays 80% and you pay 20%)
       Inpatient doctor visits                                          After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
       Preventive Care
       When using network physicians, benefits are paid at 100% after copay up to the first $500 per individual, per plan year; remaining charges will be subject to deductible
       and coinsurance. (Copays apply to any covered services provided in the doctor’s office.) Preventive care visits–network or non-network–are limited to one physical exam
       per plan year for age two and over; one OB/GYN well-woman exam per plan year; and one routine mammogram per plan year.
       Office visit (including lab, X-rays, immunizations)              $25 copay for primary/$35 copay for specialist                      After deductible, plan pays 60%; you pay 40%
       Routine eye exam (one per plan year)                             $25 copay for primary/$35 copay for specialist                      After deductible, plan pays 60%; you pay 40%
       Hearing exams                                                    $25 copay for primary/$35 copay for specialist                      After deductible, plan pays 60%; you pay 40%
       Lab and X-ray (outside the doctor's office)                                          Plan pays 100%                                  After deductible, plan pays 60%; you pay 40%
       Immunizations (outside the doctor's office)                                          Plan pays 100%                                  After deductible, plan pays 60%; you pay 40%
       Routine mammograms (outside the doctor's office)                                     Plan pays 100%                                  After deductible, plan pays 60%; you pay 40%
       Hospital/Facility Services
                                                                                                                      Preauthorization required
       Inpatient hospital (semi-private room and board or
       intensive care unit)                                             After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%

       Other inpatient charges (including surgery)                      After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%

       Outpatient hospital/facilities                                   After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
       Emergency room care within 48 hours of accident or
                                                                                                           After deductible, plan pays 80%; you pay 20%
       medical emergency
       Emergency room care for all other conditions                     After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
       Extended Care Services (preauthorization required for all services)
       Skilled nursing facility ($10,000 plan year maximum;
                                                               After deductible, plan pays 80%; you pay 20%                                 After deductible, plan pays 60%; you pay 40%
       up to $7,000 may be non-network)
       Home health care ($10,000 plan year maximum; up to
                                                               After deductible, plan pays 80%; you pay 20%                                 After deductible, plan pays 60%; you pay 40%
       $7,000 may be non-network)
       Hospice ($20,000 lifetime maximum; up to $14,000
                                                                        After deductible, plan pays 80%; you pay 20%                        After deductible, plan pays 60%; you pay 40%
       may be non-network)




4                                                    To l l - f r e e   Customer              Service:             1-866-355-5999
Payment for non-network services is limited to the allowable amount, and you are                    blood pressure or cholesterol, network retail pharmacies will charge you a higher
responsible for any balance billed by the provider, except for emergency care services              copay for a 30-day supply, beginning with the third fill. Medco By Mail will charge
(see page 13).                                                                                      you a copayment for up to a 90-day supply of your prescription. For prescriptions
                                                                                                    filled at non-network pharmacies, you will pay in full when you receive your
Network retail pharmacies will accept your TRS-ActiveCare ID card and charge you a                  medication and submit a claim form to Medco. You will be reimbursed the amount
copayment for up to a 30-day supply of your short-term prescriptions, such as                       that would have been charged by a network pharmacy, less the required copayment.
antibiotics. For long-term, maintenance medications, such as prescriptions for high                 See pages 22-25 for more information on your prescription drug benefit.




                    General Provisions                                                       Network                                                        Non-Network
  Other Medical Services
  Physical therapy
  • Office visit                                                       $25 copay for primary/$35 copay for specialist                    After deductible, plan pays 60%; you pay 40%
  • All other services                                                 After deductible, plan pays 80%; you pay 20%                      After deductible, plan pays 60%; you pay 40%
  Chiropractic care (up to $1,500 per plan year)
  • Office visit                                                                  $35 copay for specialist                         After deductible, plan pays 60%; you pay 40%
  • All other services                                                 After deductible, plan pays 80%; you pay 20%                After deductible, plan pays 60%; you pay 40%
                                                                                                              Preauthorization required
  Home Infusion Therapy
                                                                       After deductible, plan pays 80%; you pay 20%                After deductible, plan pays 60%; you pay 40%
  Hearing aids (up to $1,000 per 36-month period)                                                    After deductible, plan pays 80%; you pay 20%
  Durable medical equipment                                            After deductible, plan pays 80%; you pay 20%                After deductible, plan pays 60%; you pay 40%
  Prosthetics                                                After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
                                                              After deductible, plan pays 80% of the allowable amount; you pay the remaining 20% plus any charges
  Ambulance services (ground or air)
                                                                                   exceeding the allowable amount billed by non-network providers
  Behavioral Health (Mental Health and Chemical Dependency)
  Mental Health (preauthorization required for all services)
  Inpatient facility (up to 30 days per plan year)           After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Inpatient physician charges
                                                             After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  (up to 30 visits per plan year)
  Outpatient/office visit (up to 30 visits per plan year;
                                                             After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  non-network limited to $60 allowable per visit)
  Chemical Dependency (preauthorization required for all services) (maximum of two separate series per lifetime)
  Inpatient facility                                         After deductible, plan pays 80%; you pay 20%               After deductible, plan pays 60%; you pay 40%
  Inpatient physician charges                                          After deductible, plan pays 80%; you pay 20%                      After deductible, plan pays 60%; you pay 40%
  Outpatient                                                           After deductible, plan pays 80%; you pay 20%                      After deductible, plan pays 60%; you pay 40%
                                                                       After deductible, plan pays 80%; you pay 20%
  Office visit                                                                                                                           After deductible, plan pays 60%; you pay 40%
                                                                       $25 copay for primary/$35 copay for specialist
  Serious Mental Illness (preauthorization required for all services)
  Inpatient facility (up to 45 days per plan year)                     After deductible, plan pays 80%; you pay 20%                      After deductible, plan pays 60%; you pay 40%
  Inpatient physician (up to 45 visits per plan year)                  After deductible, plan pays 80%; you pay 20%                      After deductible, plan pays 60%; you pay 40%
  Outpatient                                                           After deductible, plan pays 80%; you pay 20%                      After deductible, plan pays 60%; you pay 40%
  Office visit (up to 60 visits per plan year)                         $25 copay for primary/$35 copay for specialist                    After deductible, plan pays 60%; you pay 40%
  Prescription Drugs*
  Retail Short-Term (up to a 30-day supply)                                                                                                 You will be reimbursed by Medco for the
  • Generic                                                                                $10 copay                                       amount that would have been charged by a
  • Preferred brand                                                                        $25 copay                                       network pharmacy less the required copay
  • Non-preferred brand                                                                    $45 copay                                         (Must submit claim to be reimbursed)
  Retail Maintenance
                                                                                                                                            You will be reimbursed by Medco for the
  (after second fill; up to a 30-day supply)
                                                                                                                                           amount that would have been charged by a
  • Generic                                                                                $15 copay
                                                                                                                                           network pharmacy less the required copay
  • Preferred brand                                                                        $35 copay
                                                                                                                                             (Must submit claim to be reimbursed)
  • Non-preferred brand                                                                    $60 copay
  Mail Order (up to a 90-day supply)
  • Generic                                                                                $20 copay
                                                                                                                                                                 N/A
  • Preferred brand                                                                      $62.50 copay
  • Non-preferred brand                                                                  $112.50 copay

* If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.




                                                             www.trs.state.tx.us/trs-activecare                                                                                                      5
    ActiveCare 3 Benefits Summary
    The benefits summary that follows shows what the plan pays for covered services and            primary care office visit and a $30 copayment for an office visit with a specialist. A
    supplies, with a comparison of network and non-network benefits. The section on How            specialist is any physician other than a family practitioner, internist, OB/GYN or
    Your Medical Plan Works found on page 8 explains in more detail the differences                pediatrician. You will pay any applicable coinsurance for other covered services. When
    between network and non-network providers. There is no deductible to meet when using           using non-network providers, the plan begins to pay benefits for covered services after
    network providers. When using a network physician, there is a $20 copayment for a              you meet the deductible.




                       General Provisions                                                   Network                                                   Non-Network
      Deductible (per plan year)
         Individual                                                                            None                                                         $500
         Family                                                                                None                                                        $1,500
      Out-of-Pocket Maximum (per plan year; does not
      include deductible or copays)
        Individual                                                                            $1,000                                                       $3,000
        Family                                                                                 N/A                                                          N/A
      Lifetime maximum benefit                                                               Unlimited                                                   $1,000,000
      Doctor and Lab Services
      Doctor office visits (includes injections, diagnostic X-rays
                                                                       $20 copay for primary/$30 copay for specialist                After deductible, plan pays 65%; you pay 35%
      and lab tests when performed during an office visit)
      Diagnostic X-rays and lab tests
                                                                                Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      (when no office visit is billed)
      Allergy injections (when no office visit is billed)                       Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      Contraceptive devices (when no office visit is billed)                    Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      Office surgery                                                            Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      Outpatient surgery                                                        Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
                                                                       $20 copay for primary/$30 copay for specialist
      Maternity care (doctor charges only; see
                                                                       (for initial visit only; for delivery, plan pays 85%          After deductible, plan pays 65%; you pay 35%
      Hospital/Facility Services for inpatient charges)
                                                                                          and you pay 15%)
      Inpatient doctor visits                                                   Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      Preventive Care
      Office visit copay includes all preventive care services billed with an office visit by a network doctor. Preventive care visits–network or non-network–are limited to one
      physical exam per plan year for age two and over; one OB/GYN well-woman exam per plan year; and one routine mammogram per plan year. Network services billed
      without an office visit will be paid at 85%.
      Office visit (including lab, X-rays, immunizations)              $20 copay for primary/$30 copay for specialist                After deductible, plan pays 65%; you pay 35%
      Routine eye exam (one per plan year)                             $20 copay for primary/$30 copay for specialist                After deductible, plan pays 65%; you pay 35%
      Hearing exams                                                    $20 copay for primary/$30 copay for specialist                After deductible, plan pays 65%; you pay 35%
      Lab and X-ray (outside the doctor's office)                               Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      Immunizations (outside the doctor's office)                               Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      Routine mammograms (outside the doctor's office.)                         Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      Hospital/Facility Services
                                                                                                                    Preauthorization required
      Inpatient hospital (semi-private room and board or
      intensive care unit)                                                      Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%

      Other inpatient charges (including surgery)                               Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%

      Outpatient hospital/facilities                                            Plan pays 85%; you pay 15%                           After deductible, plan pays 65%; you pay 35%
      Emergency room care within 48 hours of accident or
                                                                                        After $50 copay, plan pays 85%; you pay 15% (copay waived if admitted)
      medical emergency
                                                              After $50 copay, plan pays 85%; you pay 15%
      Emergency room care for all other conditions                                                                                   After deductible, plan pays 65%; you pay 35%
                                                                        (copay waived if admitted)
      Extended Care Services (preauthorization required for all services)
      Skilled nursing facility ($10,000 plan year maximum;
                                                                      Plan pays 85%; you pay 15%                                     After deductible, plan pays 65%; you pay 35%
      up to $7,000 may be non-network)
      Home health care ($10,000 plan year maximum; up to
                                                                      Plan pays 85%; you pay 15%                                     After deductible, plan pays 65%; you pay 35%
      $7,000 may be non-network)
      Hospice ($20,000 lifetime maximum; up to $14,000
                                                                      Plan pays 85%; you pay 15%                                     After deductible, plan pays 65%; you pay 35%
      may be non-network)



6                                                   To l l - f r e e   Customer             Service:           1-866-355-5999
Payment for non-network services is limited to the allowable amount, and you are                    pressure or cholesterol, network retail pharmacies will charge you a higher copay for a
responsible for any balance billed by the provider, except for emergency care services              30-day supply, beginning with the third fill. Medco By Mail will charge you a copayment
(see page 13).                                                                                      for up to a 90-day supply of your prescription. For prescriptions filled at non-network
                                                                                                    pharmacies, you will pay in full when you receive your medication and submit a claim
Network retail pharmacies will accept your TRS-ActiveCare ID card and charge you a
                                                                                                    form to Medco. You will be reimbursed the amount that would have been charged by a
copayment for up to a 30-day supply of your short-term prescriptions, such as
                                                                                                    network pharmacy, less the required copayment. See pages 22-25 for more information
antibiotics. For long-term, maintenance medications, such as prescriptions for high blood
                                                                                                    on your prescription drug benefit.




                       General Provisions                                                    Network                                                       Non-Network
  Other Medical Services
  Physical therapy
  • Office visit                                                       $20 copay for primary/$30 copay for specialist                    After deductible, plan pays 65%; you pay 35%
  • All other services                                                        Plan pays 85%; you pay 15%                                 After deductible, plan pays 65%; you pay 35%
  Chiropractic care (up to $1,500 per plan year)
  • Office visit                                                                    $30 copay for specialist                             After deductible, plan pays 65%; you pay 35%
  • All other services                                                           Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
                                                                                                                     Preauthorization required
  Home Infusion Therapy
                                                                                 Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  Hearing aids (up to $1,000 per 36-month period)                                                                Plan pays 85%; you pay 15%
  Durable medical equipment                                                      Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  Prosthetics                                                                    Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
                                                                                  Plan pays 85% of the allowable amount; you pay the remaining 15% plus any charges
  Ambulance services (ground or air)
                                                                                            exceeding the allowable amount billed by non-network providers
  Behavioral Health (Mental Health and Chemical Dependency)
  Mental Health (preauthorization required for all services)
  Inpatient facility (up to 30 days per plan year)                               Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  Inpatient physician charges
                                                                                 Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  (up to 30 visits per plan year)
  Outpatient/office visit (up to 30 visits per plan year;
                                                                                 Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  non-network limited to $60 allowable per visit)
  Chemical Dependency (preauthorization required for all services) (maximum of two separate series per lifetime)
  Inpatient facility                                                             Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  Inpatient physician charges                                       Plan pays 85%; you pay 15%                                           After deductible, plan pays 65%; you pay 35%
  Outpatient                                                        Plan pays 85%; you pay 15%                                           After deductible, plan pays 65%; you pay 35%
  Office visit                                              $20 copay for primary/$30 copay for specialist                               After deductible, plan pays 65%; you pay 35%
  Serious Mental Illness (preauthorization required for all services)
  Inpatient facility                                                             Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  Inpatient physician                                                            Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  Outpatient                                                                     Plan pays 85%; you pay 15%                              After deductible, plan pays 65%; you pay 35%
  Office visit                                                         $20 copay for primary/$30 copay for specialist                    After deductible, plan pays 65%; you pay 35%
  Prescription Drugs*
  Retail Short-Term (up to a 30-day supply)                                                                                                 You will be reimbursed by Medco for the
  • Generic                                                                                $10 copay                                       amount that would have been charged by a
  • Preferred brand                                                                        $25 copay                                       network pharmacy less the required copay
  • Non-preferred brand                                                                    $40 copay                                         (Must submit claim to be reimbursed)
  Retail Maintenance
                                                                                                                                            You will be reimbursed by Medco for the
  (after second fill; up to a 30-day supply)
                                                                                                                                           amount that would have been charged by a
  • Generic                                                                                $15 copay
                                                                                                                                           network pharmacy less the required copay
  • Preferred brand                                                                        $35 copay
                                                                                                                                             (Must submit claim to be reimbursed)
  • Non-preferred brand                                                                    $55 copay
  Mail Order
  (up to a 90-day supply)
  • Generic                                                                                $20 copay                                                             N/A
  • Preferred brand                                                                      $62.50 copay
  • Non-preferred brand                                                                   $100 copay

*If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.




                                                             www.trs.state.tx.us/trs-activecare                                                                                                     7
    How Your Medical Plan Works
    Need to locate a network or ParPlan doctor or hospital?
    Log onto www.trs.state.tx.us/trs-activecare and click on Medical Benefits, then Provider Locator. You can always call
    Customer Service at 1-866-355-5999 to confirm network status.




                                                                  Network vs. Non-Network Providers
                                          Network                                                               Non-Network
      If you need to…                     You pay lower out-of-pocket costs if you choose network care           You pay higher out-of-pocket costs if you choose non-network care
      Visit a doctor or specialist        • Visit any network doctor or specialist                               • Visit any licensed doctor or specialist
      A “specialist” is any physician     • Pay the office visit copay (not applicable for ActiveCare 1)         • Pay for the office visit
      other than a family                 • Pay any coinsurance and deductible                                   • File a claim and get reimbursed for the visit minus any
      practitioner, internist, OB/GYN     • Your doctor cannot charge more than the allowable amounts              coinsurance and deductible
      or pediatrician                       for covered services                                                 • Your costs will be based on allowable amounts; you may be
                                                                                                                   required to pay any costs over the allowable amounts
      Receive preventive care             • Visit any network doctor or specialist                               • Visit any licensed doctor or specialist
                                          • Pay the preventive care copay                                        • Pay for the preventive care visit
                                          • Pay any coinsurance and deductible                                   • File a claim and get reimbursed for the visit minus any
                                          • Your doctor cannot charge more than the allowable amounts              coinsurance and deductible
                                            for covered services                                                 • Your costs will be based on allowable amounts; you may be
                                                                                                                   required to pay any costs over the allowable amounts
      Receive emergency care              • Call 911 or go to any hospital or doctor immediately; you will receive network benefits for emergency care
                                          • Pay any copay (waived if admitted)
                                          • Pay any coinsurance and deductible (see emergency care on page 13)
                                          • Call the preauthorization number on your ID card within 48 hours
      Be admitted to the hospital         • Your network doctor will preauthorize your admission                 • You, a family member, your doctor or the hospital must
                                          • Go to the network hospital                                             preauthorize your admission
                                          • Pay any coinsurance and deductible                                   • Go to any licensed hospital
                                                                                                                 • Pay any coinsurance and deductible each time you are admitted
                                                                                                                 • Your costs will be based on allowable amounts; you may be
                                                                                                                   required to pay any costs over the allowable amounts
      Receive behavioral health or        • Call the behavioral health number on your ID card first to           • Call the behavioral health number on your ID card first to
      chemical dependency services          authorize all care                                                     authorize all care
                                          • See a network doctor or health care professional, or go to any       • See any licensed doctor or health care professional, or go to
                                            network hospital or facility                                           any licensed hospital or facility
                                          • Pay any coinsurance and deductible                                   • Pay any coinsurance and deductible
                                                                                                                 • Your costs will be based on allowable amounts; you may be
                                                                                                                   required to pay any costs over the allowable amounts
      File a claim                        Claims will be filed for you                                           You may need to file the claim yourself
      Get prescription drugs              ActiveCare 1                                                           ActiveCare 1
                                          • Take prescription to a network retail pharmacy or mail order service • Take prescription to any licensed pharmacy
                                          • Pay the discounted cost of the drug                                  • Pay the total cost of the drug
                                          • File a claim with Blue Cross and Blue Shield of Texas and get        • File a claim with Blue Cross and Blue Shield of Texas and get
                                            reimbursed for the drug minus any coinsurance and deductible           reimbursed for the drug minus any coinsurance and deductible
                                          ActiveCare 2 and ActiveCare 3                                          ActiveCare 2 and ActiveCare 3
                                          • Take prescription to a network retail pharmacy or mail order service • Take prescription to any licensed pharmacy
                                          • Pay the prescription drug copay                                      • File a claim with Medco and get reimbursed the amount that
                                                                                                                   would have been charged by a network pharmacy less the
                                                                                                                   required copay


      What is a ParPlan provider?                                                           and Blue Shield of Texas allowable amount is $80, assuming your
      ParPlan providers and contracted facilities have agreed to accept the Blue            deductible is already met, you would pay $52 ($80 x 40% coinsurance
      Cross and Blue Shield of Texas allowable amount and/or negotiated rates               = $32 + the $20 exceeding the allowable amount). In this example, if a
      for covered services. When using ParPlan providers and contracted                     network doctor is used, you would pay $16 ($80 x 20% coinsurance).
      facilities, you are covered at the non-network level and, in most cases, will
      not have to file your own claims. You will also not be responsible for any            What happens if care is not available from a network provider?
      billed amount that exceeds the allowable amount.                                      If care is not available from a network provider as determined by Blue
                                                                                            Cross and Blue Shield of Texas, and Blue Cross and Blue Shield of Texas
      What happens if a non-network provider is used?                                       preauthorizes your visit to a non-network provider prior to the visit,
      When you seek care from a network doctor or hospital, your                            network benefits will be paid. Otherwise, non-network benefits will be
      TRS-ActiveCare PPO plan pays a larger portion of your health care costs               paid, and the claim will have to be resubmitted for review and adjustment,
      than it pays for services by a non-network provider. When you receive                 if appropriate. Note: Even if approved by Blue Cross and Blue Shield of
      care outside the network, you still have coverage, but you may pay more               Texas, non-network providers paid at the network level may balance bill
      of the cost, including any charges exceeding the Blue Cross and Blue                  for charges exceeding the Blue Cross and Blue Shield of Texas allowable
      Shield of Texas allowable amount. For example, with ActiveCare 2, if a                amount for covered services. You are responsible for these charges.
      non-network doctor bills $100 for a covered service and the Blue Cross


8                                              To l l - f r e e   Customer           Service:          1-866-355-5999
Preauthorization Requirements                                            How to Preauthorize
TRS-ActiveCare requires advance approval (preauthorization) by           Medical: Network providers will preauthorize services for you.
Blue Cross and Blue Shield of Texas or INROADS Behavioral Health         If you do not use a network provider for your medical care, you are
Services for certain services. Preauthorization establishes in           responsible for preauthorization by calling Blue Cross and Blue
advance (or within 48 hours following an emergency hospital              Shield of Texas at 1-800-441-9188. (The preauthorization telephone
admission) the medical necessity of certain care and services            number also appears on your TRS-ActiveCare ID card.) This phone
covered under TRS-ActiveCare. Preauthorization ensures that care         call is important. There is a $250 penalty for failure to preauthorize
and services will not be denied on the basis of medical necessity.       a medically necessary admission to a non-network hospital. You,
However, preauthorization does not guarantee payment of benefits.        your provider, or a family member may call. The call should be
Benefits are always subject to other applicable requirements, such       made between 6 a.m. and 6 p.m. (Central Time) Monday through
as preexisting conditions, limitations and exclusions, payment of        Friday. Calls made after working hours, on weekends, or holidays
premium, and eligibility at the time care and services are provided.     will be recorded and returned the next working day.

The following types of services require preauthorization:                Serious mental illness, mental health and chemical dependency:
• All inpatient admissions                                               Preauthorization for serious mental illness, mental health and chemical
• Treatment of all serious mental illness, mental health care and        dependency should be obtained from INROADS Behavioral Health
  chemical dependency                                                    Services by calling 1-800-528-7264 between 8 a.m. and 5 p.m.
• Extended care, such as in a skilled nursing facility, through home     (Central Time). All serious mental illness, mental health and chemical
  health care or through hospice, and                                    dependency care–network and non-network, inpatient and
• Home infusion therapy.                                                 outpatient–should be preauthorized.

Care should also be preauthorized if you or your doctor wants to:
• Extend your hospital stay beyond the approved days (you or your
  doctor must call for an extension before your approved stay ends) or   What happens if services are not preauthorized?
• Transfer you to another facility or to or from a specialty unit        Blue Cross and Blue Shield of Texas will review the medical necessity of
  within the facility.                                                   your treatment prior to the final benefit determination. If the treatment or
                                                                         service is not medically necessary, benefits will be denied. There is a
Note: You must request preauthorization to use a non-network
                                                                         $250 penalty for failure to preauthorize a medically necessary admission
provider to receive the network level of benefits. Preauthorization
                                                                         to a non-network hospital. The penalty will be deducted from any benefit
for medical necessity of services does not guarantee network level
                                                                         payment that may be due for the admission. The penalty is in addition to
of benefits. Even if approved by Blue Cross and Blue Shield of Texas,
                                                                         the deductible or out-of-pocket maximum.
non-network providers paid at the network level may balance bill for
charges exceeding the Blue Cross and Blue Shield of Texas                Is there a time limit for preauthorizing hospital
allowable amount for covered services.                                   admissions?
                                                                         All inpatient admissions should be preauthorized at least two working
                                                                         days before admission, or in the case of an emergency, within 48 hours
                                                                         after admission.




                                              www.trs.state.tx.us/trs-activecare                                                                        9
     How to request or replace an ID card
     To request additional cards or to replace lost or damaged cards,
     call Customer Service at 1-866-355-5999, or log on to Blue
     Access for Members through the TRS-ActiveCare Web site to
     order ID cards online. There is no charge for ID cards.




     Accessing the BlueCard Program                                                       3. When you arrive at the doctor's office or hospital, present your
     for Health Care Outside Texas                                                           TRS-ActiveCare ID card, and the doctor or hospital will verify
     Your benefits travel with you. Your TRS-ActiveCare ID card features the                 eligibility and coverage information.
     Blue Cross and Blue Shield symbols and the PPO-in-a-suitcase logo                    4. After you receive medical attention, the network provider will file
     telling providers that you are part of the BlueCard program. This means                 claims for you.
     that you and your covered dependents may use Blue Cross and Blue                     5. You will be responsible for paying any applicable deductible,
     Shield network providers throughout the United States. Follow these                     copayment or coinsurance amounts, as well as any charges for
     steps to receive the network (highest) level of benefits offered under                  non-covered services. BlueCard providers have agreed to accept the
     your plan while traveling or away from home:                                            Blue Cross and Blue Shield Plan's allowable amount for covered
     1. If you are outside of Texas and need health care, refer to your                      services and will not balance bill you for any cost exceeding the
        TRS-ActiveCare ID card and call BlueCard Access at 1-800-810-                        allowable amount.
        BLUE (2583) for information on the nearest network doctors and
        hospitals.
     2. Although network providers outside of Texas may preauthorize those
       services that require preauthorization (such as a hospital admission),
       it is ultimately your responsibility to obtain preauthorization by calling
       the appropriate number on the back of your TRS-ActiveCare ID card.



       Does TRS-ActiveCare provide benefits for medical services                          In an emergency, go directly to the nearest hospital.
       outside the United States?                                                         Call Blue Cross and Blue Shield of Texas for preauthorization if necessary.
       Yes. Through the BlueCard Worldwide program, you have access to                    (Refer to the phone number on the back of your TRS-ActiveCare ID card.
       hospitals on almost every continent and to a broad range of medical                The preauthorization phone number is different than the BlueCard Access
       assistance services when you travel or live outside the United States.             number above).
       BlueCard Worldwide provides the following services:                                In most cases, you will not need to pay for inpatient care at BlueCard
       • Provider location                                                                Worldwide hospitals in advance. The hospital should submit your claim. You
       • Referral information                                                             will, however, be responsible for the usual out-of-pocket expenses
       • Medical monitoring                                                               (non-covered services, deductible, copayment, and coinsurance amounts).
       • Wire transfers/overseas mailing
                                                                                          If you do not use a BlueCard Worldwide provider for care, you will need to
       • Translation
                                                                                          pay the doctor or hospital at the time of service. Then, you will need to
       • Coverage verification
                                                                                          complete an international claim form and send it to the BlueCard Worldwide
       • Currency conversion
                                                                                          Service Center. The claim form is available online at www.trs.state.tx.us/trs-
       If you need to locate a doctor or hospital, or need medical assistance,            activecare. Non-network benefits will apply towards covered expenses.
       call BlueCard Access at (800) 810-BLUE (2583) or call collect at
                                                                                          Remember that bills from foreign providers differ from billing in the
       (804) 673-1177, 24 hours a day, seven days a week. A medical assistance
                                                                                          United States. The bills may be missing the provider's name and address, in
       coordinator, in conjunction with a medical professional, will arrange
                                                                                          addition to other critical information. It is very important that you fill out the
       hospitalization, if necessary. Network benefits will apply for inpatient care at
                                                                                          BlueCard Worldwide claim form completely and attach your bills from the
       BlueCard Worldwide hospitals.
                                                                                          foreign provider. Missing information will delay claims processing.




10                                             To l l - f r e e   Customer          Service:        1-866-355-5999
What the Medical Plan Covers
The following medical expenses are covered by TRS-ActiveCare. The descriptions have been alphabetized for quick
reference. Covered services may be subject to other plan limitations. Refer to the specific Benefits Summary for the
TRS-ActiveCare plan you selected on pages 2–7 of this booklet for more detailed information, including the
applicable copay, deductible and coinsurance.




Acquired Brain Injury
                                                                            What is the allowable amount?
Benefits for eligible expenses incurred for medically necessary
                                                                            Covered medical expenses are payable at the Blue Cross and Blue
treatment of an acquired brain injury will be determined on the             Shield of Texas allowable amount. The allowable amount is the
same basis as treatment for any other physical condition. Eligible          maximum amount that will be considered by TRS-ActiveCare for a
expenses include neurobehavioral, neurophysiological, and                   medical service or supply. The allowable amount is determined by Blue
                                                                            Cross and Blue Shield of Texas and is based on the negotiated rates
neuropsychological services, and psychophysiological testing or
                                                                            with providers; Blue Cross and Blue Shield of Texas rates for the same
treatment as a result of and related to an acquired brain injury.           service by providers in the same geographic area with similar training,
                                                                            experience and facilities; or any other recognized source. For multiple
Allergy Care
                                                                            surgeries performed on the same patient on the same day, the
Coverage is provided for testing and treatment for medically                allowable amount will be the amount for the single procedure with the
necessary allergy care. Allergy injections are not considered               highest allowable amount, plus one half of the allowable amount for
immunizations for purposes of the TRS-ActiveCare preventive                 each of the other procedures performed. You are responsible for any
                                                                            balance billed by a non-network provider. Exception: If you are treated
care benefit.
                                                                            by a non-network provider in a network hospital during the first 48
Ambulance Services                                                          hours of your emergency, benefits will be paid at the network level
                                                                            based on the billed amount instead of the allowable amount.
TRS-ActiveCare provides coverage for professional local ground
                                                                            Ambulance services will be paid up to the allowable amount.
ambulance or air ambulance transportation services received at the
                                                                            What does medically necessary mean?
time of an emergency and when determined to be medically
                                                                            Supplies and services are covered only if they are medically necessary.
necessary by Blue Cross and Blue Shield of Texas. There are no              This means that the services and supplies must be:
benefits available for ambulance services unless a patient is               • Essential to and provided for diagnosis or treatment of a medical condition
transported to the nearest hospital equipped and staffed to treat the       • Proper for the symptoms, diagnosis or treatment of a medical condition
                                                                            • Performed in the proper setting or manner required for a medical condition
condition. Ambulance services will be paid up to the allowable
                                                                            • Within the standards of generally accepted health care practice as
amount. Many areas are served by ambulance services that do not               determined by Blue Cross and Blue Shield of Texas, and
contract with any provider networks. These services often charge            • The most economical supplies or levels of service appropriate for safe
more than TRS-ActiveCare will pay, and you will be responsible for            and effective treatment.
charges exceeding the Blue Cross and Blue Shield of Texas                   Medically necessary charges do not include charges for:
allowable amount.                                                           • A service or supply that is provided only as a convenience
                                                                            • Repeated tests that are not needed, even if ordered by a doctor
Chemical Dependency Treatment (preauthorization required)                   • Services which are experimental, investigational, or educational
Chemical dependency is the abuse of, psychological or physical                in nature, or
dependency on, or addiction to alcohol or a controlled substance.           • All other non-covered services and supplies.

All chemical dependency treatment–inpatient and outpatient,                 Medical necessity is determined by Blue Cross and Blue Shield of Texas.
network or non-network–must be preauthorized.                               A determination of medical necessity does not guarantee payment
                                                                            unless the service is covered by the TRS-ActiveCare plan.
There is a maximum limit of two separate series of chemical
dependency treatments per lifetime. A series of treatments is a
planned, structured, and organized program to promote chemical-            these levels of treatments without a lapse in treatment. A series is
free status. A program may include different facilities or modalities,     complete when a participant is discharged on medical advice or
such as inpatient detoxification, inpatient rehabilitation/treatment,      when a participant fails to materially comply with the treatment
partial hospitalization or intensive outpatient treatment or a series of   program for a period of 30 days.



                                              www.trs.state.tx.us/trs-activecare                                                                            11
     Inpatient treatment of chemical dependency must be provided in a            Dental Services and Covered Oral Surgery
     substance abuse facility. Benefits for the medical management of            General dental services are not covered by TRS-ActiveCare.
     acute, life-threatening intoxication (toxicity) in a hospital will be
                                                                                 When medically necessary and prescribed by your doctor, covered oral
     available on the same basis as any other illness.
                                                                                 surgery is limited to:
     Chiropractic Care                                                           • Excision of non-dental related neoplasms, including benign
     TRS-ActiveCare pays benefits for services (including occupational             tumors and cysts, and all malignant and premalignant lesions and
     therapy) and supplies provided by or under the direction of a Doctor          growths
     of Chiropractic. There is a $1,500 maximum benefit per person, per          • Incision and drainage of facial abscess
     plan year.                                                                  • Surgical procedures involving salivary glands and ducts and non-
                                                                                   dental related procedures of the accessory sinuses
     Cosmetic, Reconstructive, or Plastic Surgery
                                                                                 • Surgical and diagnostic treatment of conditions affecting the
     For cosmetic, reconstructive or plastic surgery, TRS-ActiveCare
                                                                                   temporomandibular joint (including the jaw and the
     covers only the following services if medically necessary:
                                                                                   craniomandibular joint) due to accident, trauma, congenital
     • Treatment for correction of defects due to accidental injury while
                                                                                   defects and developmental defects or a pathology
       covered under TRS-ActiveCare. (The condition that the accident
                                                                                 • Services provided to a newborn for treatment or correction of a
       occurs while the participant is covered by TRS-ActiveCare does
                                                                                   congenital defect
       not apply to initial enrollees and new hires.)
                                                                                 • Correction of damage caused solely by external violent
     • Reconstructive surgery following cancer surgery
                                                                                   accidental injury to healthy natural teeth and supporting tissues,
     • Treatment and surgery to correct a congenital defect in a newborn
                                                                                   if the accident occurs while the participant is covered by
     • Surgery to correct a congenital defect in a dependent child (other than
                                                                                   TRS-ActiveCare. (The condition that the accident occurs while the
       a newborn child) under age 19. This does not include breast surgery.
                                                                                   participant is covered by TRS-ActiveCare does not apply to initial
     • Reconstruction of the breast on which a mastectomy has been
                                                                                   enrollees and new hires.) Services must be received within 24
       performed; surgery and reconstruction of the other breast to achieve
                                                                                   months of the date of the accident. An injury sustained as a
       a symmetrical appearance; and prostheses and treatment of
                                                                                   result of biting or chewing is not considered to be an accidental
       physical complications, including lymphedemas, at all stages of the
                                                                                   injury; and
       mastectomy
                                                                                 • Orthognathic surgery
     • Reconstructive surgery on a dependent child under age 19 due to
       craniofacial abnormalities to improve the function of, or attempt to      Facility and related services, when medically necessary, are covered
       create a normal appearance of, an abnormal structure caused by            for participants who are unable to undergo treatment in a dental
        congenital defects, developmental deformities, trauma, tumors,           office or under local anesthesia due to a documented physical, mental,
        infections, or disease                                                   or medical reason (preauthorization required). The dental-related
     • Reduction mammoplasty                                                     services are not covered.
     Benefits for eligible expenses will be the same as for the treatment
     of any other sickness as shown on the Benefits Summary for the
     specific TRS-ActiveCare plan you selected.




12                                          To l l - f r e e   Customer      Service:    1-866-355-5999
Diabetic Management Services                                              Emergency Care
TRS-ActiveCare covers expenses associated with the treatment of           Your TRS-ActiveCare plan covers medical emergencies wherever
diabetes for individuals diagnosed with insulin-dependent or              they occur. In case of emergency, call 911 or go to the nearest
non-insulin-dependent diabetes, elevated blood glucose levels             emergency room. If you are treated by a non-network provider in a
induced by pregnancy, or another medical condition associated with        network hospital during the first 48 hours of your emergency,
elevated blood glucose levels. Covered items include:                     benefits will be paid at the network level based on the billed
• Diabetic Equipment and Supplies                                         amount instead of the allowable amount. Ambulance services will
  • Covered under your Medical Benefits: Insulin pumps and                be paid up to the allowable amount.
    necessary accessories, infusion devices, and podiatric                • Inpatient care: If you are admitted to a network hospital,
    appliances for the prevention of complications associated with          network providers will preauthorize your hospital admission and
    diabetes. Non-prescriptive oral agents are also covered.                you will receive the network level of benefits. If you are admitted
  • Covered under your Pharmacy Benefits: Insulin, blood                    to a non-network hospital, the hospital admission must be
    glucose monitors (up to $100 per year), test strips for blood           preauthorized within 48 hours by calling 1-800-441-9188. If the
    glucose monitors, visual reading and urine test strips, lancets         non-network hospital admission is not preauthorized, there is a
    and lancet devices, insulin analogs, injection aids, syringes, and      $250 penalty, and benefits will be paid at the non-network level.
    glucagon emergency kits.                                                If the admission to the non-network hospital was medically
• Diabetes Self-management Training Programs                                necessary and due to an accident or emergency, you can contact
  (Covered under your Medical Benefits):                                    Blue Cross and Blue Shield of Texas to appeal the original
  • Training provided after the initial diagnosis of diabetes on the        decision and request payment at the network level of benefits.
   care and management of that condition, including nutritional
                                                                          • Outpatient care: Network benefits are available for treatment
    counseling and proper use of diabetic equipment and supplies
                                                                            received within the first 48 hours following an accident or
  • Additional training provided after a diagnosed significant change
                                                                            medical emergency (even in a non-network facility). Treatment
    in symptoms or condition that requires changes in the self-
                                                                            received after 48 hours of an onset of an accident or medical
    management program, and
                                                                            emergency in a non-network facility will be paid at the
  • Training as warranted by the development of new techniques
                                                                            non-network level of benefits.
    and treatments for diabetes.
Durable Medical Equipment                                                   What is an emergency?
TRS-ActiveCare covers the rental (or purchase at the discretion             An emergency is the sudden onset of a medical condition manifesting
of Blue Cross and Blue Shield of Texas) of therapeutic supplies and         itself by acute symptoms of sufficient severity, including severe pain,
rehabilitative equipment required for therapeutic use, such as a            that would lead a prudent layperson possessing an average knowledge
standard wheelchair, crutches, walker, bedside commode, hospital-           of medicine and health to believe that the person's condition, sickness
type bed, suction machine, artificial respirator, or similar equipment.     or injury is of such a nature that failure to get immediate care could
                                                                            result in:
Equipment to alleviate pain or provide patient comfort (for example,        • Placing the person’s health in serious jeopardy
over-the-counter splints or braces, air conditioners, humidifiers,          • Serious impairment to bodily functions
dehumidifiers, air purifiers, physical fitness and whirlpool bath           • Serious dysfunction of any bodily organ or part
equipment, personal hygiene protection and home air fluidized               • Serious disfigurement, or
beds) is not covered, even if prescribed by your doctor.                    • In the case of a pregnant woman, serious jeopardy to the health
                                                                              of the fetus



                                             www.trs.state.tx.us/trs-activecare                                                                       13
     Family Planning                                                           Home Infusion Therapy (preauthorization required)
     Covered services include:                                                 TRS-ActiveCare covers the administration of fluids, nutrition or
     • Insertion and removal of an intrauterine device (IUD)                   medication (including all additives and chemotherapy) by
     • Fitting a diaphragm                                                     intravenous (IV) or gastrointestinal (enteral) infusion or by
     • Vasectomy                                                               intravenous injection in the home setting. Home infusion therapy
     • Tubal ligation                                                          includes:
     • Insertion or removal of birth control device implanted under            • Drugs and IV solutions
        the skin                                                               • Pharmacy compounding and dispensing services
                                                                               • All equipment and ancillary supplies necessitated by the
     Oral contraceptives are included under the TRS-ActiveCare
                                                                                  defined therapy
     prescription drug benefit.
                                                                               • Delivery services
     Hearing Aids                                                              • Patient and family education, and
     Benefits are available for hearing aids, including fittings and molds,    • Nursing services
     up to $1,000 per 36-month period. Hearing aids must be paid for
                                                                               Over-the-counter products which do not require a prescription,
     in advance, and claims for covered expenses must be submitted to
                                                                               including standard nutritional formulations used for enteral nutrition
     Blue Cross and Blue Shield of Texas for reimbursement.
                                                                               therapy, are not covered.
     TRS-ActiveCare does not cover replacement for loss, damage
                                                                               Hospice Care (preauthorization required)
     or functional defect. Hearing aid repair and batteries are also
                                                                               TRS-ActiveCare covers services provided by a hospice to patients
     not covered.
                                                                               confined at home or in a hospice facility due to a terminal sickness
     Home Health Care (preauthorization required)                              or terminal injury requiring skilled health care services.
     TRS-ActiveCare covers medically necessary services and supplies
                                                                               The following services are covered for home hospice care:
     provided in the patient’s home during a visit from a home health
                                                                               • Part-time or intermittent nursing care by a registered nurse (RN)
     agency as part of a physician’s written home health care plan.
                                                                                 or licensed vocational nurse (LVN)
     Coverage includes:
                                                                               • Part-time or intermittent home health aide services for
     • Part-time or intermittent nursing care by a registered nurse (RN)
                                                                                 patient care
       or licensed vocational nurse (LVN)
                                                                               • Physical, respiratory, and speech therapy by licensed
     • Part-time or intermittent home health aide services for
                                                                                 therapists, and
       patient care
                                                                               • Homemaker and counseling services, including
     • Physical, occupational, speech, and respiratory therapy services
                                                                                 bereavement counseling
       provided by licensed therapists, and
     • Supplies and equipment routinely provided by the home                   Covered facility hospice care includes:
       health agency                                                           • All usual nursing care by a registered nurse (RN) or licensed
                                                                                 vocational nurse (LVN)
     Home health care benefits are not provided for food or home-
                                                                               • Room and board and all routine services, supplies and
     delivered meals, social casework or homemaker services,
                                                                                 equipment provided by the hospice facility
     transportation, or services provided primarily for custodial care.
                                                                               • Physical, speech and respiratory therapy services by licensed
                                                                                 therapists, and
                                                                               • Counseling services routinely provided by the hospice facility,
                                                                                 including bereavement counseling




14                                        To l l - f r e e   Customer      Service:    1-866-355-5999
Hospital Admission (preauthorization required)
                                                                            What happens if lab and X-ray work are performed
TRS-ActiveCare covers room and board (up to the hospital’s
                                                                            outside the doctor’s office, or the lab work and X-rays
semiprivate room rate), general nursing care, and other hospital            are sent to another location for interpretation?
services and supplies. It does not cover personal items such as             ActiveCare 1 and ActiveCare 2: If the lab and X-ray services
telephones and television rental.                                           performed outside the doctor's office are for preventive care, they will
                                                                            be paid at 100% of the allowable amount up to a $500 maximum per
Infertility Services                                                        plan year when using network physicians. Charges over the $500
Testing for problems of infertility is covered. Coverage is also            maximum will be subject to deductible and coinsurance (plan pays
                                                                            80%; you pay 20%). Lab and X-ray services due to non-preventive
provided for prescription fertility drugs under the TRS-ActiveCare
                                                                            diagnoses will also be subject to deductible and coinsurance.
prescription drug benefit.
                                                                            ActiveCare 3: For lab and X-ray services performed outside the
Note: Services or supplies provided for, in preparation for, or in          doctor's office, the plan pays 85% of the allowable amount and you
conjunction with in vitro fertilization and artificial insemination are     pay 15% for covered services when using network physicians.
not covered. See page 20 for additional exclusions.                         Are non-network specialists such as anesthesiologists,
                                                                            radiologists and pathologists covered at the network
Lab and X-Ray Services
                                                                            level of benefits if the hospital or surgeon is in the
Medically necessary laboratory and radiographic procedures,                 network?
services and materials, including diagnostic X-rays, X-ray therapy,         These services will be paid at the network benefits level. However,
chemotherapy, fluoroscopy, electrocardiograms, laboratory tests, and        payment for non-network services is limited to the allowable amount,
                                                                            and you are responsible for any balance billed by the provider, except
therapeutic radiology services are covered when ordered by a
                                                                            for emergency care services (see page 13).
provider.

Network providers are responsible for referring patients to network       In some situations, a provider or facility will refer the results of lab
labs, imaging centers or an outpatient department of a network            tests and X-rays to a radiologist or pathologist for a professional
hospital for medically necessary lab and X-ray services that are not      interpretation of the results. Since participants have little or no
available in a provider's office. However, you should always remind       control over this referral, all professional interpretations for lab and
your provider that you will receive a higher level of benefits offered    X-ray will be paid at the network level of benefits whether performed
under your plan when using network providers.                             by a network or non-network provider. However, if a non-network
                                                                          provider is used, the participant will be responsible for any expenses
If care is not available from a network provider as determined by
                                                                          exceeding the allowable amount.
Blue Cross and Blue Shield of Texas and Blue Cross and Blue Shield
of Texas preauthorizes your visit to a non-network provider prior to
the visit, network benefits will be paid. Otherwise, non-network
benefits will be paid and the claim will have to be resubmitted for
review and adjustment, if appropriate. If a non-network provider is
used, the participant will be responsible for any expenses exceeding
the allowable amount.




                                               www.trs.state.tx.us/trs-activecare                                                                      15
     Maternity Care                                                                      Mental Health Care (preauthorization required)
     TRS-ActiveCare covers maternity-related expenses for employees and                  TRS-ActiveCare covers charges for inpatient and outpatient mental
     covered dependents.                                                                 health care for:
                                                                                         • Diagnosis or treatment of a symptom, disease, disorder, or
     Maternity care includes diagnosis of pregnancy, pre- and post-natal
                                                                                           condition (as defined by the American Psychiatric Association in
     care and delivery (including delivery by Caesarean section).
                                                                                           the latest edition of the Diagnostic and Statistical Manual of
     TRS-ActiveCare covers inpatient care for the mother and newborn
                                                                                           Mental Disorders of the American Psychiatric Association or any
     child in a health care facility for a minimum of 48 hours following an
                                                                                           other diagnostic coding system used by Blue Cross and Blue
     uncomplicated vaginal delivery, and for a minimum of 96 hours
                                                                                           Shield of Texas) whether or not the cause of the disease, disorder
     following an uncomplicated delivery by Caesarean section.
                                                                                           or condition is physical, chemical or mental in nature or origin
     Inpatient hospital expenses incurred by the mother for delivery of a
                                                                                         • Diagnosis or treatment of any symptom, condition, disease or
     child will not include charges for routine well-baby nursery care of
                                                                                           disorder by a provider, or any person working under the
     the newborn child during the mother's hospital admission for the
                                                                                           supervision of a provider, when the eligible expense is:
     delivery. These charges will be considered expenses of the child
                                                                                           • Individual, group, family, or conjoint psychotherapy
     and will be subject to the benefit provisions and benefit maximums
                                                                                           • Counseling
     described in the Benefits Summary of the specific TRS-ActiveCare
                                                                                           • Psychoanalysis
     plan you selected.
                                                                                           • Psychological testing and assessment
                                                                                           • For administering or monitoring of psychotropic drugs
        How is maternity care covered?
                                                                                           • Hospital visits or consultations in a facility providing such care
        ActiveCare 1: Maternity care is subject to the applicable deductible
        and coinsurance. ActiveCare 2 and ActiveCare 3: You pay the office               • Electroconvulsive treatment
        visit copay for your initial visit. For the duration of your pregnancy, you
                                                                                         • Psychotropic drugs (covered under your pharmacy benefits)
        pay your applicable deductible and coinsurance.
                                                                                         All mental health care–inpatient and outpatient, network or
        How is a newborn child covered under TRS-ActiveCare?
        TRS-ActiveCare automatically provides coverage for a newborn child of            non-network–must be preauthorized. Refer to the Benefits
        a covered employee for the first 31 days after the date of birth. To add         Summary of the TRS-ActiveCare plan you selected for day or visit
        coverage for the newborn, you must sign, date and submit an                      limitations that apply.
        Enrollment Application and Change Form to your Benefits Administrator
        within 60 days after the date of birth. However, you have up to one              Medically necessary mental health care in a psychiatric day
        year after the newborn's date of birth to add the newborn to coverage            treatment facility, a crisis stabilization unit or facility, or a residential
        if: (1) the child is born on or after September 1, 2004, and (2) you             treatment center for children and adolescents, in lieu of
        have employee and family or employee and child(ren) coverage with
                                                                                         hospitalization, will be considered inpatient hospital expense. Each
        TRS-ActiveCare at the time of the newborn’s birth. If the application is
        submitted after the enrollment period for the newborn child, the request         full day of mental health care in a psychiatric day treatment facility,
        to add coverage will be denied—even if there would be no change in               crisis stabilization unit or facility, or residential treatment center for
        premium.                                                                         children and adolescents will count as a half day of inpatient care.
        Newborn grandchildren are not covered automatically. If eligible, the            Newborn Screening Tests for Hearing Impairment
        grandchild must be added to the employee's coverage for benefits. An
                                                                                         TRS-ActiveCare covers screening tests for hearing loss from birth
        eligible grandchild must primarily reside in the employee's household
        and must be a dependent of the employee for federal income tax                   through the date the child is 30 days old (unless a delay is medically
        purposes.                                                                        necessary) and necessary diagnostic follow-up care related to
                                                                                         screening tests from birth through the date the child is 24 months old.



16                                             To l l - f r e e   Customer            Service:    1-866-355-5999
Organ and Tissue Transplants (preauthorization required)                  which are a separable part of a covered brace; specially ordered,
Organ and tissue transplants (bone marrow, cornea, heart,                 custom-made or built-up shoes, cast shoes, shoe inserts designed
heart/lung, kidney, kidney/pancreas, liver, lung) and related services    to support the arch or effect changes in the foot; or foot alignment,
and supplies are covered if the:                                          arch supports, elastic stockings and garter belts.
• Transplant is not experimental/investigational in nature
                                                                          Note: Foot orthotics are covered for the treatment of diabetes.
• Donated human organs or tissue are used
                                                                          Maintenance and repairs to orthotics resulting from accident,
• Recipient or donor is a participant under TRS-ActiveCare
                                                                          misuse or abuse are the participant’s responsibility.
• Transplant procedure is preauthorized
• Recipient meets all of the criteria established by Blue Cross and       Outpatient Facility Services
  Blue Shield of Texas in its written medical policy guidelines, and      TRS-ActiveCare covers the following services provided through a
• Recipient meets all of the protocols established by the hospital        hospital outpatient department or a free-standing facility when
  in which the transplant is performed                                    medically necessary:
Covered services and supplies include:                                    • Radiation therapy
• Evaluation of organs or tissues including, but not limited to, the      • Chemotherapy
  determination of tissue matching                                        • Dialysis
• Removal of organs or tissues from deceased donors                       • Rehabilitation services
• Transportation and storage of donated organs and tissues                • Outpatient surgery

Services and supplies not covered by TRS-ActiveCare include:              Preventive Care
• Living and/or travel expenses of the live donor or recipient            TRS-ActiveCare encourages preventive care and maintenance of
• Donor search and acceptability testing of potential living donors       good health. Covered services under this benefit must be billed by
• Expenses related to maintenance of life for purposes of organ or        the provider as “preventive care.” Preventive care benefits include:
  tissue donation                                                         • Routine physical exams (limited to one physical exam per plan
• Purchase of the organ or tissue                                            year for persons age two and over and one well-woman exam
• Medical expenses of a recipient or donor who is not a participant         per plan year)
  under TRS-ActiveCare                                                    • Routine mammograms (one per plan year)
Orthotics                                                                 • Immunizations (injections for allergies are not
TRS-ActiveCare covers orthopedic braces (i.e., an orthopedic                considered immunizations)
appliance used to support, align, or hold body parts in a correct         • Well baby exams
position) and crutches, including rigid back, leg or neck braces; casts   • Vision exams (one per plan year)
for treatment of any part of the legs, arms, shoulders, hips or back;     •   Hearing exams
special surgical and back corsets; and physician-prescribed, -directed,   •   Prostate (PSA) screenings
or -applied dressings, bandages, trusses, and splints which are           •   Colorectal cancer screenings
custom-designed for the purpose of assisting the function of a joint.     •   Osteoporosis screenings
                                                                          •   Bone density screenings
Non-covered items include, but are not limited to, an orthodontic or
other dental appliance (except as allowed for accidental injury           Note: A routine colonoscopy performed in the doctor’s office and
under covered oral surgery on page 12); splints or bandages               billed with a preventive diagnosis and procedure code is covered
provided by a physician in a non-hospital setting or purchased over-      under preventive care.
the-counter for support of strains and sprains; orthopedic shoes


                                             www.trs.state.tx.us/trs-activecare                                                                   17
     Professional Services
     Covered services must be medically necessary and provided by a                Who are covered health providers?
     licensed doctor. Services may also be provided by other covered
                                                                                   TRS-ActiveCare provides benefits for services provided only by the
     health providers. See box to the right. Benefits for services for
                                                                                   following providers:
     diagnosis and treatment of illness or injury are available on an
     inpatient or an outpatient basis or in a provider's office.                   • Doctor of Medicine
                                                                                   • Doctor of Osteopathy
     Prosthetic Devices                                                            • Doctor of Podiatry
     TRS-ActiveCare provides coverage for medically necessary artificial           • Doctor in Psychology
     devices including limbs or eyes, braces or similar prosthetic or orthopedic   • Psychological Associates who work under the supervision of a Doctor
     devices, which replace all or part of:                                          in Psychology
                                                                                   • Doctor of Optometry
     • An absent body organ (including contiguous tissue), or
                                                                                   • Doctor of Chiropractic
     • The function of a permanently inoperative or malfunctioning body
                                                                                   • Doctor of Dentistry
       organ (excluding dental appliances and the replacement of                   • Licensed Audiologist
       cataract lenses)                                                            • Licensed Speech-Language Pathologist
                                                                                   • Licensed Master Social Worker-Advanced Clinical Practitioner
     For purposes of this definition, a wig or hairpiece is not considered
                                                                                   • Licensed Dietician
     a prosthetic appliance.                                                       • Licensed Professional Counselor
     Maintenance and repairs to prosthetic devices resulting from                  • Licensed Hearing Instrument Fitter
                                                                                   • Licensed Chemical Dependency Counselor
     accident, misuse or abuse are the participant’s responsibility.
                                                                                   • Licensed Occupational Therapist
     Rehabilitation Services                                                       • Licensed Physical Therapist
     (Physical, Speech and Occupational Therapies)                                 • Advanced Practice Nurse (APN)
                                                                                   • Physician Assistant (PA)
     TRS-ActiveCare covers rehabilitation services and physical, speech
                                                                                   • Nurse First Assistant (NFA)
     and occupational therapies that are medically necessary, meet or
     exceed treatment goals for a participant, and are provided on an
     inpatient or outpatient basis or in the provider's office. For a
     physically disabled person, treatment goals may include
     maintenance of function or prevention or slowing of further
     deterioration.




18                                          To l l - f r e e   Customer        Service:    1-866-355-5999
Serious Mental Illness (preauthorization required)
Benefits for the treatment of serious mental illness will be provided on     Transitional Care
the same basis as any other illness. Serious mental illness means the        Transitional care applies only to initial enrollees as of the date
following psychiatric illnesses as defined by the American Psychiatric       the district/entity begins participating in TRS-ActiveCare;
Association in the latest edition of the Diagnostic and Statistical Manual   transitional care does not apply to new hires.
of Mental Disorders of the American Psychiatric Association:                 If you or a covered dependent are undergoing a course of
• Bipolar disorders (hypomanic, manic, depressive, and mixed)                medical treatment at the time of enrolling in ActiveCare 1, 2 or 3
• Depression in childhood and adolescence                                    and your doctor is not in the PPO network, ongoing care with
• Major depressive disorders (single episode or recurrent)                   the current doctor may be requested for a period of time.
• Obsessive-compulsive disorders                                             Transitional care benefits may be available if being treated for
• Paranoid and other psychotic disorders                                     any of the following conditions by a non-network doctor:
• Pervasive developmental disorders                                          • Pregnancy (third trimester or high risk)
• Schizo-affective disorders (bipolar or depressive)                         • Newly diagnosed cancer
• Schizophrenia                                                              • Terminal illness
Medically necessary care for serious mental illness in a psychiatric         • Recent heart attack
day treatment facility, a crisis stabilization unit or facility, or a        • Other ongoing acute care
residential treatment center for children and adolescents, in lieu of        Transitional care benefits are subject to approval. To request
hospitalization, will be considered inpatient hospital expense. Each         transitional care benefits, complete a Transitional Care
full day of mental health care in a psychiatric day treatment facility,      Request Form available from your Benefits Administrator or on
crisis stabilization unit or facility, or residential treatment center for   the Web site. Instructions for submitting the request to Blue
children and adolescents will count as a half day of inpatient care.         Cross and Blue Shield of Texas are on the form. If the
Skilled Nursing Facility (preauthorization required)                         transitional care request is approved, you or your covered
TRS-ActiveCare covers care in a skilled nursing facility and pays            dependent may continue to see the non-network doctor and
benefits for:                                                                receive the network level of benefits from the selected TRS-
• Room and board up to the semiprivate room rate                             ActiveCare plan. If the transitional care request is denied, you
• Routine medical services, supplies, and equipment provided by              may still continue to see your current doctor, but benefits will
  the skilled nursing facility                                               be paid at the non-network level.
• General nursing care by a registered nurse (RN) or licensed                If your doctor is in the network, you do not have to complete a
  vocational nurse (LVN)                                                     Transitional Care Request Form.
• Physical, occupational, speech therapy, and respiratory therapy
  services by a licensed therapist




                                                 www.trs.state.tx.us/trs-activecare                                                               19
     What the Medical Plan Does Not Cover                                           • Services or supplies provided in connection with an occupational
                                                                                      sickness or an injury sustained in the scope of and in the course of
     In addition to the limitations and exclusions set out in the description
                                                                                      any employment, whether or not benefits are or could be provided
     of What the Medical Plan Covers, beginning on page 11,
                                                                                      under Workers’ Compensation
     TRS-ActiveCare does not cover medical expenses for the following:
                                                                                    • Items for patient convenience or comfort as determined by
     • As determined by Blue Cross and Blue Shield of Texas, services or
                                                                                      Blue Cross and Blue Shield of Texas
       supplies that are not medically necessary or any
       experimental/investigational services or supplies                            • Dietary and nutritional services and supplies except for an inpatient
                                                                                      nutritional assessment program provided in and by a hospital and
     • Charges resulting from the failure to keep a scheduled visit with a
                                                                                      approved by Blue Cross and Blue Shield of Texas, diabetic
       physician or other professional provider, for the completion of any
                                                                                      management services that are provided by a physician and
       insurance forms, or for the acquisition of medical records
                                                                                      approved by Blue Cross and Blue Shield of Texas, or medically
     • Vision services or supplies, including but not limited to, orthoptics,         necessary dietary supplements required for the treatment of
       vision training, vision therapy, radial keratotomy, contact lenses or          Phenylketonuria (PKU)
       the fitting of contact lenses, eyeglasses, photoreflective keratotomy,
                                                                                    • Services or supplies provided before the participant's effective date
       and LASIK
                                                                                      of coverage or after the expiration date of coverage
     • Cosmetic, reconstructive, or plastic surgery except as allowed
                                                                                    • Charges that would not be made if you did not have health
       provided for on page 12
                                                                                      coverage or charges that you are not legally required to pay
     • General dental services, including dental appliances (except for
                                                                                    • Services or supplies provided by a person, entity, facility or hospital
       appliances as allowed for accidental injury under covered oral
                                                                                      that has not been approved as a network or non-network provider
       surgery on page 12)
                                                                                      by Blue Cross and Blue Shield of Texas
     • Any items of medical/surgical expense incurred for dental surgery
                                                                                    • Room and board charges during a hospital admission for diagnostic
       except as allowed on page 12
                                                                                      or evaluative procedures, unless Blue Cross and Blue Shield of
     • Services or supplies for routine foot care, including shoe orthotics,          Texas determines that inpatient status is medically necessary
       insoles, or shoe inserts of any type (except when prescribed for a
                                                                                    • Marriage and family therapy/counseling, self-therapy, or therapy as
       diagnosis of, or related to, diabetes)
                                                                                      a part of training
     • Services or supplies provided for obesity or weight reduction, except
                                                                                    • Travel services and accommodations, whether or not recommended
       for medically necessary treatment of morbid obesity as determined
                                                                                      or prescribed, except ambulance services
       by Blue Cross and Blue Shield of Texas
                                                                                    • Services or supplies provided for, in preparation for, or in
     • Services or supplies provided for injuries sustained as a result of
                                                                                      conjunction with: sterilization reversal (male or female); transsexual
       war, declared or undeclared, or any act of war or while on active or
                                                                                      surgery; sexual dysfunction; in vitro fertilization; or promotion of
       reserve duty in the armed forces of any country or international
                                                                                      fertility through extra-coital reproductive technologies including, but
       authority
                                                                                      not limited to, artificial insemination, intrauterine insemination, super
     • Services or supplies provided for treatment or related services to             ovulation uterine capacitation enhancement, direct intra-peritoneal
       the temporomandibular joint (TMJ), except for medically necessary              insemination, transuterine tubal insemination, gamete intra-fallopian
       diagnostic/surgical treatment                                                  transfer, pronuclear oocyte state transfer, zygote intra-fallopian
                                                                                      transfer, and tubal embryo transfer




20                                          To l l - f r e e   Customer         Service:    1-866-355-5999
• Abortion, unless the participant's life would be endangered by              • Any occupational therapy services that do not consist of traditional
  continuing the pregnancy, there is a diagnosed fetal anomaly, or the          physical therapy modalities and are not part of a rehabilitation
  pregnancy is caused by a criminal act such as rape or incest                  program designed to restore lost or impaired body functions

• Transplant procedures which Blue Cross and Blue Shield of Texas             • Any portion of a charge for a service or supply that is in excess of
  considers experimental and/or investigational in nature                       the allowable amount as determined by Blue Cross and Blue Shield
                                                                                of Texas, except for emergency care services (see page 13)
• Medical social services, bereavement counseling (except as part of
  a preauthorized hospice treatment plan), or vocational counseling           • Any services or supplies not specifically defined as eligible
                                                                                expenses, unless pre-approved through case management by
• Environmental sensitivity, clinical ecology, or inpatient allergy testing
                                                                                Blue Cross and Blue Shield of Texas
  or treatment
                                                                              • Services or supplies for custodial care as determined by
• Chelation therapy except for treatment of acute metal poisoning
                                                                                Blue Cross and Blue Shield of Texas
• Prescription drugs or medicines that are covered under a separate
                                                                              • Telemedicine services provided by telephone or fax machine
  prescription drug program with its own limitations and exclusions
                                                                              • Services or supplies provided by an immediate family member
• Acupuncture, videofluroscopy, intersegmental traction, surface
                                                                                (spouse, child or self)
  EMGs, manipulation under anesthesia, and muscle testing through
  computerized kinesiology machines such as Isostation, Digital
  Myograph, and Dynatron



    What are preexisting conditions?                                           Does TRS-ActiveCare coverage have preexisting
    Preexisting conditions are conditions for which you or your                condition limitations or exclusions?
    dependent received medical advice, diagnosis, care, or for which           For initial enrollees (those eligible employees and dependents
    treatment was recommended or received during the six months                enrolling when TRS-ActiveCare is first made available through
    before your effective date of coverage under TRS-ActiveCare.               their participating district/entity) and new hires, there are no
                                                                               preexisting condition exclusions so long as you enroll when you
    If you or a dependent has a preexisting condition before your
                                                                               are first eligible for coverage. If you do not enroll during your
    medical coverage starts, TRS-ActiveCare may deny benefits for
                                                                               initial period of eligibility, a 12-month preexisting condition
    that condition until you have been covered 12 months by
                                                                               exclusion period will apply if you elect coverage during a future
    TRS-ActiveCare.
                                                                               plan enrollment period or due to a special enrollment event. If
    The preexisting condition provision does not apply to:                     you decline coverage during any plan enrollment period in which
    • A newborn child (special rules apply to newborns; see box on             ActiveCare 1, 2, or 3 was offered to you, a 12-month preexisting
      page 16 for more information)                                            condition exclusion period will apply if you elect coverage in the
    • A person who was covered for 12 months under creditable coverage         future. Prior creditable coverage may be used to offset a
    • Pregnancies                                                              preexisting condition exclusion period as provided under the
    • Conditions resulting from domestic violence                              Health Insurance Portability and Accountability Act of 1996
    • Genetic information without a diagnosis of a specific condition          (HIPAA). There are no preexisting condition exclusions for HMO
    All other terms and provisions, limitations and exclusions apply           coverage.
    to all employees and covered dependents even if a preexisting
    condition exclusion does not apply for the reasons above.


                                                www.trs.state.tx.us/trs-activecare                                                                     21
     How Your Prescription Drug Program Works
     The pharmacy benefits for ActiveCare 1 are administered by Blue Cross and Blue Shield of Texas; the pharmacy
     benefits for ActiveCare 2 and ActiveCare 3 are administered by Medco Health Solutions, Inc. (Medco).




      ActiveCare 1                                                            Long-Term Medications and Medco By Mail
      Retail Pharmacy Services                                                Beginning September 1, 2004, unless you use Medco By Mail for
      Participating retail pharmacies will accept your TRS-ActiveCare ID      your long-term prescriptions, you may be required to pay more for
      card and charge you the negotiated Medco price for up to a 30-day       these medications. Receiving your long-term prescriptions through
      supply of your prescription. You will be required to pay in full when   mail order could mean significant savings for you.
      you receive your medication and submit a claim form to Blue Cross
                                                                              Here’s how it works: The first two times you buy your long-term
      and Blue Shield of Texas for reimbursement. The plan will treat this
                                                                              prescription at a participating retail pharmacy, you will make your
      as a medical claim and will pay benefits after you meet the
                                                                              usual retail pharmacy copayment. After that, you will pay a higher
      deductible.
                                                                              cost for your long-term prescription.
      Your retail pharmacy service is most convenient when you need a
                                                                              With Medco By Mail, you can get up to a 90-day supply of your
      medication for a short period. For example, if you need an
                                                                              prescription and make just one copayment. If you fill your
      antibiotic to treat an infection, you can go to one of the many
                                                                              prescription at a retail pharmacy, however, you could pay a higher
      pharmacies that participate in the TRS-ActiveCare program and get
                                                                              amount for the same 90-day supply (three 30-day fills). Please see
      your medication on the same day. You may save money by using
                                                                              charts on the next page for the copay amounts. If you need
      Medco participating network pharmacies for your short-term
                                                                              medication on an ongoing or long-term basis, such as you might
      prescriptions.
                                                                              need to treat asthma or diabetes, you can ask your doctor to
      Medco By Mail                                                           prescribe up to a 90-day supply for mail order, plus refills for up to
      By using Medco By Mail, you can receive up to a 90-day supply of        one year.
      covered medication. You will be required to pay in full when you
                                                                              You should continue to get all your short-term drugs, such as
      receive your medication and submit a claim form to Blue Cross and
                                                                              antibiotics, at a retail pharmacy and pay your usual copayment.
      Blue Shield of Texas for reimbursement. The plan will treat this as a
      medical claim and will pay benefits after you meet the deductible.      Note: Certain long-term medications are not subject to the above
                                                                              conditions. Insulin and diabetic supplies, for example, may be
      Medco By Mail offers you convenience and potential cost savings.
                                                                              purchased at retail with no increase in copay on the third or
      If you need medication on an ongoing or long-term basis, such as
                                                                              subsequent fills. A listing of drugs that are subject to the conditions
      you might need to treat asthma or diabetes, you can ask your
                                                                              above may be found at: www.trs.state.tx.us/trs-activecare.
      doctor to prescribe up to a 90-day supply for home delivery, plus
      refills for up to one year.                                             Prescription Drug Formulary
                                                                              ActiveCare 2 and ActiveCare 3 plans include a formulary, which is a
      ActiveCare 2 and ActiveCare 3
                                                                              list of drugs indicating preferred and non-preferred status. Each
      Retail Pharmacy Services
                                                                              drug is Food and Drug Administration (FDA) approved and is also
      Your retail pharmacy service is most convenient when you need a
                                                                              reviewed by an independent group of doctors and pharmacists for
      medication for a short period. For example, if you need an
                                                                              safety and efficacy. TRS-ActiveCare encourages the use of the
      antibiotic to treat an infection, you can go to one of the many
                                                                              preferred drugs on this list to help control rising prescription
      pharmacies that participate in the TRS-ActiveCare program and get
                                                                              drug costs.
      your medication on the same day.




22                                       To l l - f r e e   Customer     Service:     1-866-355-5999
   Can prescription drug copayments be used to satisfy the plan year deductible and out-of-pocket maximum?
   ActiveCare 1: Yes. The cost of your prescription drugs will apply to your medical plan year deductible and out-of-
   pocket maximum.
   ActiveCare 2 and ActiveCare 3: No. Your prescription drug copayments do not apply to your medical plan year
   deductible or out-of-pocket maximum.




ActiveCare 2 Pharmacy Benefit Copays
 Short-term drugs (such as antibiotics)
                                                                   You pay                              You pay                              You pay
 Where                           When                              Generic drug                         Preferred brand-name drug            Non-preferred brand-name drug
                                 Anytime a medication is           $10 per prescription filled          $25 per prescription filled          $45 per prescription filled
 Participating retail pharmacy
                                 prescribed for short-term use     for up to a 30-day supply            for up to a 30-day supply            for up to a 30-day supply
                                 Not advisable for                 Not advisable for                    Not advisable for                    Not advisable for
 Medco By Mail
                                 short-term drugs                  short-term drugs                     short-term drugs                     short-term drugs
 Long-term drugs (those you take for three months or more, such as those used to treat high blood pressure or high cholesterol)
                                                                   You pay                              You pay                              You pay
 Where                           When                              Generic drug                         Preferred brand-name drug            Non-preferred brand-name drug
                                 First 2 times you purchase each $10 per prescription filled for up     $25 per prescription filled for up   $45 per prescription filled for up
 Participating retail pharmacy
                                 prescription drug after 9/1/2004 to a 30-day supply                    to a 30-day supply                   to a 30-day supply
                                 Beginning with the 3rd time
                                                                   $15 per prescription filled for up   $35 per prescription filled for up   $60 per prescription filled for up
 Participating retail pharmacy   you purchase each prescription
                                                                   to a 30-day supply                   to a 30-day supply                   to a 30-day supply
                                 drug after 9/1/2004
                                 Anytime you purchase a           $20 per prescription filled for up    $62.50 per prescription filled for $112.50 per prescription filled
 Medco By Mail
                                 prescription drug after 9/1/2004 to a 90-day supply                    up to a 90-day supply              for up to a 90-day supply




ActiveCare 3 Pharmacy Benefit Copays
 Short-term drugs (such as antibiotics)
                                                                   You pay                              You pay                              You pay
 Where                           When                              Generic drug                         Preferred brand-name drug            Non-preferred brand-name drug
                                 Anytime a medication is           $10 per prescription filled          $25 per prescription filled          $40 per prescription filled
 Participating retail pharmacy
                                 prescribed for short-term use     for up to a 30-day supply            for up to a 30-day supply            for up to a 30-day supply
                                 Not advisable for                 Not advisable for                    Not advisable for                    Not advisable for
 Medco By Mail
                                 short-term drugs                  short-term drugs                     short-term drugs                     short-term drugs
 Long-term drugs (those you take for three months or more, such as those used to treat high blood pressure or high cholesterol)
                                                                   You pay                              You pay                              You pay
 Where                           When                              Generic drug                         Preferred brand-name drug            Non-preferred brand-name drug
                                 First 2 times you purchase each $10 per prescription filled for up     $25 per prescription filled for up   $40 per prescription filled for up
 Participating retail pharmacy
                                 prescription drug after 9/1/2004 to a 30-day supply                    to a 30-day supply                   to a 30-day supply
                                 Beginning with the 3rd time
                                                                   $15 per prescription filled for up   $35 per prescription filled for up   $55 per prescription filled for up
 Participating retail pharmacy   you purchase each prescription
                                                                   to a 30-day supply                   to a 30-day supply                   to a 30-day supply
                                 drug after 9/1/2004
                                 Anytime you purchase a           $20 per prescription filled for up    $62.50 per prescription filled for $100 per prescription filled for
 Medco By Mail
                                 prescription drug after 9/1/2004 to a 90-day supply                    up to a 90-day supply              up to a 90-day supply

ActiveCare 2 and ActiveCare 3
• If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between
  the brand-name drug and the generic drug.
• Remember: You should continue to purchase short-term drugs, such as antibiotics, at a participating retail pharmacy.
• For copayment information for non-network pharmacies, see the Benefits Summaries on pages 2 to 7.
• If you need more information, visit www.trs.state.tx.us/trs-activecare, or call Customer Service at 1-866-355-5999, option “1.”




                                                     www.trs.state.tx.us/trs-activecare                                                                                           23
     Get the information you need online.
     Visit the link to Medco through the Web site at www.trs.state.tx.us/trs-activecare to compare costs
     of generic vs. brand-name drugs, calculate mail-order savings, access medication information and
     more. First-time visitors should take a minute to register to access all the benefits of the site — be
     sure to have your ID number and a recent prescription number handy when you register.




     What is the difference between long-term and short-term drugs?                   What about drug interactions?
     Long-term drugs are those you take on an ongoing basis (three months or          The prescription drugs that you get through Medco By Mail, as well as those
     more), such as those used to treat high blood pressure or high                   purchased from a participating retail pharmacy, are checked for potential
     cholesterol. Short-term drugs include antibiotics and other medications          drug interactions. If Medco ever has a question about your prescription, a
     that you take for short periods of time. You can view a list of long-term        Medco pharmacist will contact your doctor prior to dispensing the
     (or “maintenance”) medications on the Medco link at                              medication. If your doctor decides to change the prescription, Medco will
     www.trs.state.tx.us/trs-activecare.                                              send a notification letter to you and to your doctor.

     How long does it take to get my medications when I use                           What happens if I am covered by TRS-ActiveCare and also have a
     Medco By Mail?                                                                   Medicare discount card for prescription drugs?
     First-time orders that you mail to Medco will be delivered to you within         ActiveCare 1: You cannot use your TRS-ActiveCare ID card and your
     seven to 11 days after you mail in the order. If your doctor faxes your          Medicare discount card for the same prescription. Choose the card that
     prescription, you will receive your medications within five to eight days        offers the best discount for your prescription. Remember, to maximize your
     after your doctor faxes the order.                                               cost savings using your TRS-ActiveCare ID card, you should use Medco
                                                                                      participating retail pharmacies. Regardless of which card you use, you will
     What if I need to speak with a pharmacist?                                       pay 100% of the cost at the time of purchase and will be reimbursed 80%
     Just call toll-free 1-866-355-5999, option “1.” Medco-registered                 after your deductible has been met. Submit claims to Blue Cross and Blue
     pharmacists are available for medication consultations 24 hours a day,           Shield of Texas.
     seven days a week.
                                                                                      ActiveCare 2 and ActiveCare 3: You cannot use your TRS-ActiveCare ID
     Can I still use a participating retail pharmacy?                                 card and your Medicare discount card for the same prescription. At a
     Yes. You should go to a participating retail pharmacy for medications that you   participating Medco retail pharmacy, you pay any applicable copay with your
     take on a short-term basis, such as antibiotics, and you will pay your           TRS-ActiveCare ID card or the discounted cost of the prescription if you
     participating retail pharmacy copayment. If you prefer, you can continue to      choose to use your Medicare discount card. If you use either card at a non-
     receive long-term drugs from a participating retail pharmacy. However, you       network pharmacy, you will pay 100% of the cost at the time of purchase
     will pay more for each long-term drug at a participating retail pharmacy after   and will be reimbursed the amount that would have been charged by a
     the second time you fill the prescription, beginning September 1, 2004.          network pharmacy less the required copay. Submit Medicare discount card
                                                                                      claims and claims from a non-network pharmacy to Medco.


 The Generic Drug Advantage                                                           version of your medication is available and whether it would be
 Important: For both mail order and the retail pharmacy, if you obtain a              right for you. By using a generic drug, you will receive a high-quality
 brand-name drug when a generic equivalent is available, you are                      medication that may reduce your expenses.
 responsible for the generic copayment plus the cost difference between
                                                                                      Exclusions from Pharmacy Benefits
 the brand-name drug and the generic drug.
                                                                                      Examples of, but not a complete listing of, categories that are
 Generic drugs may have unfamiliar names, but they are safe and                       excluded are:
 effective. Be assured that generic drugs and their brand-name                        • Non-federal legend drugs
 counterparts:                                                                        • Ostomy supplies
 • Have the same active ingredients and                                               • Allergy serums
 • Are manufactured according to the same strict federal regulations.                 • Blood or blood plasma products
                                                                                      • Implantable contraceptives
 Generic drugs may differ in color, size, or shape, but the FDA requires
                                                                                      • Experimental drugs
 that they have the same strength, purity, and quality as the brand-name
                                                                                      • Drugs whose sole purpose is to promote or stimulate hair growth
 alternatives.
                                                                                        (e.g. Rogaine, Propecia) or for cosmetic purposes only (e.g.
 Prescriptions filled with generic drugs often have lower copayments.                   Renova, Vaniqua)
 Therefore, you may be able to get the same health benefits at a lower                • Retin-A/Avita for use by individuals age 35 and over
 cost. You should ask your doctor or pharmacist whether a generic



24                                            To l l - f r e e   Customer         Service:      1-866-355-5999
Note: Other drugs may be excluded under the plan. To find out if your
drug is excluded under TRS-ActiveCare, follow the links to the Medco            How to Get Your Prescriptions Filled
Web site under the “Medical Pharmacy Benefits” page at                          Retail Pharmacies
www.trs.state.tx.us/trs-activecare. There, you can look up the drug by          Filling short-term prescriptions can be fast and easy when you use a
name (online registration required).                                            retail network pharmacy. These pharmacies will accept your ID card
                                                                                and charge you the appropriate copayment when you fill a prescription
Prescription Limitations                                                        covered by TRS-ActiveCare. To find out whether a pharmacy
Some drugs or therapeutic classes of drugs may have limitations based           participates in TRS-ActiveCare:
upon accepted clinical guidelines, dosage limitations, recommended              • Ask your pharmacist
standards of care and/or shelf life stability limits.                           • Visit the Web site at www.trs.state.tx.us/trs-activecare and use the
                                                                                  online pharmacy locator
Consult the www.trs.state.tx.us/trs-activecare Web site for an updated          • Call 1-866-355-5999 and use the automated pharmacy locator
list of these managed drug classes. These programs include:
                                                                                Medco By Mail
• Traditional Prior Authorization: Certain medications require review           With the mail order pharmacy service:
    and authorization from your physician prior to dispensing.
• Smart Prior Authorization: Certain medications require review                 • Your medications are dispensed by a mail order pharmacy and
                                                                                  shipped to your home.
    and authorization by your physician if you have a prescription for
    more than the usually allowed quantity or dose of medication over           • Medications are shipped by standard delivery at no additional cost
    time, or in cases when evidence of prior therapy in a step                    to you. (Express shipping is available for an added charge.)
    approach is not found.                                                      • You can order and track your prescriptions online through the Medco
• Quantity Per Dispensing Event: Sets dispensing quantity limits                  link at www.trs.state.tx.us/trs-activecare, or you can telephone your
    per copayment on a few categories of drugs.                                   order to Medco toll-free at 1-800-473-3455.
• Dose Optimization: Voluntary program that seeks to educate                    • Registered pharmacists are available around the clock for medication
    patients and physicians on optimizing dosing of multiple lower                consultations.
    strength medications into higher strengths where clinically
                                                                                There are two easy ways to get started with Medco By Mail.
    appropriate.
Special Care Pharmacy                                                           Option 1 - Mail in your prescription:
The Medco Special Care Pharmacy service is designed to help you meet            Step 1: Ask your doctor for a new prescription for up to a 90-day
                                                                                supply, plus refills for up to one year (as appropriate). Make sure you
the particular needs and challenges of using certain medications, many
                                                                                have a two-week supply on hand while you wait for your mail order
of which require injection or special handling. If you are taking a specialty   prescription to arrive.
pharmacy medication, you will be eligible to receive additional services        Step 2: Mail the new prescription using Medco’s order form and
when you fill your specialty prescriptions using Medco By Mail. These           envelope. Order forms are available on the TRS Web site at
additional services include:                                                    www.trs.state.tx.us/trs-activecare, or you may call Customer Service at
• Support and guidance from Medco nurses and pharmacists who                    1-866-355-5999, option “1.” You may pay for your mail order by
                                                                                credit card, check, or money order. Your prescription will arrive within
    are trained in these medications, their side effects, and the
                                                                                seven to 11 days after your order is received.
    conditions they treat
• Expedited delivery of all your specialty prescription medications             Option 2 - Have your doctor fax your prescription:
                                                                                Step 1: Follow Step 1 in the Mail section above.
• Supplemental supplies, such as needles and syringes that are
                                                                                Step 2: Provide your doctor with your ID number (located on your
    required to administer the medication, at no additional charge
                                                                                TRS-ActiveCare ID card), and ask him or her to call 1-888-327-9791
• Scheduling of refills and coordination of services with home care             for instructions on how to use Medco’s fax service. You will be billed
    providers, case managers, and doctors or other health care                  later. Your prescription will arrive within five to eight days after your
    professionals                                                               doctor faxes the order.



                                                www.trs.state.tx.us/trs-activecare                                                                          25
     Plan Provisions                                                          school or college students are all eligible for coverage, provided
                                                                              no exception applies, if they are employees, not volunteers, and
                                                                              are either active, contributing TRS members or are employed
     Who is eligible for TRS-ActiveCare coverage?                             for 10 or more hours each week. True on-call substitutes,
     Teachers, administrative personnel, permanent substitutes, bus           independent contractors, and volunteers are not employees
     drivers, librarians, crossing guards, cafeteria workers, and high        and are therefore not eligible for TRS-ActiveCare coverage.




     Employee Eligibility                                                       • Another child in a regular parent-child relationship with the
     Who can enroll in TRS-ActiveCare?                                            employee, meaning:
     To be eligible for TRS-ActiveCare, an individual must be employed            • The child's primary residence is the household of the employee;
     by a participating entity. Then, answer the following questions:             • The employee provides at least 50% of the child's support;
     (1) Is the individual an active, contributing TRS member?                    • Neither of the child's natural parents resides in that
     (2) Is the individual employed for 10 or more hours each week?                 household; and
                                                                                  • The employee has the legal right to make decisions regarding
     If the answer is yes to either question, then the employee is eligible
                                                                                    the child's medical care
     for TRS-ActiveCare coverage unless the individual is also:
                                                                                • A grandchild whose primary residence is the household of the
     • Receiving health care coverage as an employee or retiree under
                                                                                  employee and who is a dependent of the employee for federal
       the State University Employees Uniform Insurance Benefits Act.
                                                                                  income tax purposes.
       Example: A school employee who has UT Select coverage as an
       employee with The University of Texas.                                   A child of a covered employee, regardless of age, may be eligible
     • Receiving health care coverage as an employee or retiree                 for dependent coverage if the child is either mentally retarded or
       under the Texas Employees Group Benefits Act. Example:                   physically incapacitated to such an extent as to be dependent on
       A school employee who has HealthSelect coverage as an                    the employee on a regular basis and the child meets other
       employee with ERS.                                                       requirements as determined by TRS.
     • A TRS retiree receiving, or who waived coverage, under                   If an employee and spouse both work for a participating
       TRS-Care, including a retiree who has returned to work.                  district/entity, the spouse may be covered as an employee or as a
     Note: Although a retiree, a higher education employee or a state           dependent of an eligible employee. Only one parent may enroll
     employee may not be covered as an employee of a participating              dependent children for coverage.
     entity, he or she can be covered as a dependent of an eligible
     employee.                                                                  An unmarried child (under age 25) who is employed by a
                                                                                participating entity and is a contributing TRS member cannot be
     Eligible Dependents                                                        covered as a dependent on his or her parent's TRS-ActiveCare
     You may also enroll your eligible dependents at the same time you          coverage. This child must be covered as an employee of the
     enroll for coverage. Eligible dependents of a covered employee include     participating entity. If the child is not a contributing TRS member,
     a spouse (including a common law spouse) and an unmarried child            the child may be covered as a dependent.
     under the age of 25 described by any of the following:
     • A natural or adopted child
     • A stepchild
     • A foster child
     • A child under the legal guardianship of the employee




26                                        To l l - f r e e   Customer     Service:      1-866-355-5999
                                                                             Changes in coverage must be made within 31 days after the
  Unmarried (Including Divorced) Children under the                          special enrollment event. (Special rules apply to newborns; see
  Age of 25
  An employee may enroll an unmarried child under the age of 25 who          box on page 16 for more information.) If you do not request the
  meets TRS-ActiveCare eligibility requirements for dependent coverage. If   appropriate changes during the applicable special enrollment period,
  a married child under the age of 25 obtains a divorce and the employee     the changes cannot be made until the next plan enrollment period or
  wants to enroll the child after the initial enrollment period in
                                                                             if applicable, another special enrollment event. A preexisting
  TRS-ActiveCare, the employee must submit an Enrollment
  Application and Change Form within 31 days after the date of the           condition exclusion period may apply.
  divorce. Coverage for the child will be effective on the first of the
                                                                             Even if you have a special enrollment event, change employment to
  month following the date of the divorce.
                                                                             another participating district/entity or leave and become
  This same policy applies to children who obtain an annulment of their      re-employed by your same district/entity, you may not make plan
  marriage and who meet the other TRS-ActiveCare eligibility
                                                                             changes during a plan year unless specifically permitted by
  requirements.
                                                                             TRS rules.
  The employee will be responsible for any increase in premium that
  results from enrolling the child.                                          Note: The COBRA election period is separate from the
                                                                             TRS-ActiveCare enrollment period(s). For example, you have 60 days
                                                                             to elect COBRA coverage with a prior employer, but you must elect
Making Changes/Special Enrollment Events                                     TRS-ActiveCare coverage within 31 days of the loss of coverage.
You may be able to enroll yourself and change the dependents you cover
during a plan year if you have a special enrollment event such as:
• You marry or divorce (if the divorce results in a loss of                    Can dependents be added throughout the plan year?
                                                                               An employee can add dependents during a plan year if the employee
  other coverage)                                                              has a qualified status change or special enrollment event. Such events
• A child is born, adopted, or is placed with you for adoption such            include marriage, divorce, birth or adoption of a child, or a loss of
  that you have a legal obligation to support that child                       coverage from another group plan. The change in coverage must be
                                                                               consistent with the family status change. For example, if an employee
• A child marries or reaches age 25
                                                                               gets married, the coverage category can be changed from employee-
• A court orders you to provide health coverage for your child, or             only coverage to employee and spouse.
• You or your dependent loses other health insurance coverage (and
  you originally declined TRS-ActiveCare coverage in writing
  because of coverage under another health benefit plan).

The change in coverage must be consistent with the family status
change. For example, if you get married, you can change from
employee-only coverage to employee and spouse coverage.
The cost of coverage may change based on the selected
coverage category.




                                               www.trs.state.tx.us/trs-activecare                                                                       27
     Loss of coverage                                                         Court-Ordered Dependent Children
     Loss of coverage does not qualify as a special enrollment                Employees may add a court-ordered dependent child to coverage
     event unless:                                                            within 31 days from the date the district/entity receives
     • You and/or your dependent(s) lost other coverage due to a loss of      notification of the court order or national medical support
       eligibility, or                                                        notice. A court order or national medical support notice is not a
     • You and/or your dependent(s) elected to drop the other group           special enrollment event for an employee. If you are not covered by
       health coverage because the employer stopped all employer              TRS-ActiveCare at the time the district/entity receives the court
       contributions toward the premium, or                                   order or notice, your court-ordered dependent child(ren) may be
     • You and/or your dependent(s) exhausted your COBRA                      enrolled for coverage, but you cannot enroll for employee coverage
       continuation coverage                                                  until the next enrollment period or until you experience a special
                                                                              enrollment event.
     The following reasons for dropping coverage do not qualify as
     special enrollment events:                                               If the district/entity receives notice of the court order or national
     • An increase in the premium cost                                        medical support notice to add coverage for your dependent
     • A reduction in the employer’s contribution to the premium              child(ren), the child(ren) may be added to your current
     • Dropping COBRA continuation coverage before the coverage               TRS-ActiveCare plan if you are covered. If you are not covered,
       is exhausted                                                           you may select a plan for the dependent child(ren).
     • Any other voluntary termination of coverage, including failure to
                                                                              Request for Exceptions
       pay your premium
                                                                              Enrollment Application and Change Forms submitted to your Benefits
     If you submit an Enrollment Application and Change Form due to           Administrator after the applicable enrollment period will be denied.
     “loss of other coverage,” your original application will be checked to   You may submit a request to TRS for an exception by writing to:
     verify that coverage was declined (in section 9) due to other            TRS-ActiveCare, 1000 Red River Street, Austin, TX 78701. Such
     coverage. If section 9 was not completed or if no application            requests will be reviewed on a case-by-case basis.
     exists, proof of coverage (such as a certificate of creditable
     coverage) in lieu of a declination of coverage on the enrollment
     application must be provided to your Benefits Administrator. If
     documentation is not made available, your request to add coverage
     will be denied.
     Note: For TRS-ActiveCare, the loss of coverage from the following
     also qualifies as a special enrollment event:
     • Medicare
     • Medicaid
     • CHIP
     • Individual coverage when outside the control of the individual. For
        example: The insurance company claims bankruptcy, the
       insurance company withdraws from doing business in the state,
       or the insurance company cancels the block of business




28                                                www.trs.state.tx.us/trs-activecare
Effective Date of Coverage
The effective date is the date TRS-ActiveCare coverage begins for a participant.
See the chart below to help determine the effective date of coverage.




If …                                                       Your effective date is…                                  Your eligible dependent's          The preexisting
                                                                                                                    effective date is…                 condition exclusion
                                                                                                                                                       applies…
Your district/entity first begins participation in         September 1, 2004                                        September 1, 2004                  No
TRS-ActiveCare on September 1, 2004 and you enroll
for coverage during spring or summer enrollment…
Your district/entity begins participation in               Your choice of:                                          The same date as your effective No
TRS-ActiveCare after September 1, 2004 and you enroll      (1) the date the district/entity first begins            date of coverage
for coverage…                                              participation in TRS-ActiveCare, or                      In no event will the dependent's
                                                           (2) the first of the month in which your TRS             coverage become effective prior
                                                           membership begins                                        to your effective date
                                                           You must choose the effective date of coverage by
                                                           the end of the initial plan enrollment period
You enroll for coverage during the 2004-2005               September 1, 2004                                        September 1, 2004                  Yes (unless enrolling in an
enrollment period and had originally declined coverage                                                                                                 HMO option)
under TRS-ActiveCare…
A new hire in a TRS-covered position who is a TRS          Your choice of:                                          The same date as your effective No
member on his or her actively-at-work date enrolls for     (1) your actively-at-work date, or                       date of coverage
coverage within 31 days after the actively-at-work         (2) the first of the month following your                In no event will the dependent's
date…                                                      actively-at-work date                                    coverage become effective prior
                                                           Premium is billed for the full month in which            to your effective date
                                                           coverage begins
                                                           New hires must choose the effective date of coverage
                                                           within 31 days after the actively-at-work date
A new hire in a TRS-covered position who, because          Your choice of:                                          The same date as your effective No
of the 90-day waiting period, is not yet a TRS member      (1) your actively-at-work date                           date of coverage
but is regularly scheduled to work 10 or more hours        (2) the first of the month following your actively-at-   In no event will the dependent's
per week on his or her actively-at-work date enrolls       work date, or                                            coverage become effective prior
for coverage within 31 days after the actively-at-work     (3) the first of the month in which your TRS             to your effective date
date…                                                      membership begins
                                                           Premium is billed for the full month in which
                                                           coverage begins
                                                           New hires must choose the effective date of coverage
                                                           within 31 days after the actively-at-work date
A new hire in a TRS-covered position who, because of       Your choice of:                                          The same date as your effective No
the 90-day waiting period, is not yet a TRS member and     (1) your TRS membership effective date, or               date of coverage
is not regularly scheduled to work 10 or more hours per    (2) the first of the month following your TRS            In no event will the dependent's
week on his or her actively-at-work date enrolls for       membership effective date                                coverage become effective prior
coverage within 31 days after TRS membership                                                                        to your effective date
                                                           Premium is billed for the full month in which
begins…
                                                           coverage begins
For example: A bus driver who is not a TRS member is
                                                           New hires must choose the effective date of
hired on May 11 and is scheduled to work 9 hours per
                                                           coverage within 31 days after the TRS membership
week. His or her TRS membership will be effective on
                                                           effective date
August 10, following the 90-day waiting period. The bus
driver may choose August 10 or September1 as the
effective date of coverage. The bus driver must sign,
date and submit an enrollment application to the
Benefits Administrator within 31 days after August 10,
the TRS membership effective date.
A new hire in a non-TRS-covered position who is            Your choice of:                                          The same date as your effective No
regularly scheduled to work 10 or more hours per week      (1) your actively-at-work date, or                       date of coverage
on his or her actively-at-work date enrolls for coverage   (2) the first of the month following your actively-at-   In no event will the dependent's
within 31 days after the actively-at-work date…            work date                                                coverage become effective prior
                                                           Premium is billed for the full month in which            to your effective date
                                                           coverage begins
                                                           You must choose the effective date of coverage
                                                           within 31 days after the eligibility date


                                                     www.trs.state.tx.us/trs-activecare                                                                                              29
     If …                                                         Your effective date is…                                 Your eligible dependent's                The preexisting
                                                                                                                          effective date is…                       condition exclusion
                                                                                                                                                                   applies…
     Your status changes and you become eligible for              Your choice of:                                         The same date as your effective          No
     coverage during the plan year (example: the employee         (1) your eligibility date, or                           date of coverage
     increases hours and begins to work 10 or more hours          (2) the first of the month following your eligibility   In no event will the dependent's
     per week) and enrolls for coverage within 31 days after      date                                                    coverage become effective prior
     the date you become an eligible employee…                                                                            to your effective date
                                                                  Premium is billed for the full month in which
     Note: If you meet eligibility requirements as regularly      coverage begins
     scheduled to work 10 or more hours per week and
                                                                  You must choose the effective date of coverage
     decline coverage, you may not elect coverage later
                                                                  within 31 days after the eligibility date
     during that plan year if changing status to a TRS
     member. (Changing TRS membership status is not an
     enrollment event.)
     You are enrolled in an approved HMO and lose eligibility     The first of the month following the event date         The same date as your effective          No
     because you no longer live, work or reside in that HMO                                                               date of coverage
     service area, you may enroll in another approved HMO                                                                 In no event will the dependent's
     (if applicable) or ActiveCare 1, 2 or 3 within 31 days                                                               coverage become effective prior
     after losing eligibility...                                                                                          to your effective date
                                                             Your choice of:
     You return from military service and enroll (or re-enroll)                                                           The same date as the employee's          No
     in TRS-ActiveCare within 31 days after your actively-at-(1) your actively-at-work date                               effective date of coverage
     work date…                                              (2) the first of the month following your actively-at-       In no event will the dependent's
     If you return to active employment within the same plan work date, or                                                coverage become effective prior
     year and choose to re-enroll in TRS-ActiveCare, you     (3) the first of the month in which your TRS                 to your effective date
     must select the same plan option in which you were      membership begins
     previously enrolled.                                    Premium is billed for the full month in which
                                                             coverage begins
                                                                  You must choose the effective date of coverage
                                                                  within 31 days after the actively-at-work date
     You return from leave-without-pay status and enroll (or Your choice of:                                              The same date as your effective          No
     re-enroll) for coverage within 31 days after your       (1) your actively-at-work date                               date of coverage
     actively-at-work date…                                  (2) the first of the month following your                    In no event will the dependent's
     If you return to active employment within the same plan actively-at-work date, or                                    coverage become effective prior
     year and choose to re-enroll in TRS-ActiveCare, you     (3) the first of the month in which your TRS                 to your effective date
     must select the same plan option in which you were      membership begins
     previously enrolled.                                    Premium is billed for the full month in which
                                                             coverage begins
                                                                  You must choose the effective date of coverage
                                                                  within 31 days after the actively-at-work date
     As a covered employee you have a newborn child and                                                                   The newborn’s date of birth              No (for the newborn)
     choose to enroll:                                                                                                    Note: If enrolling a spouse who was Yes (for the spouse,
     (1) your newborn only, or                                                                                            covered under a participating district unless enrolling in an
     (2) your spouse only, or                                                                                             on the newborn’s date of birth, the    HMO option)
     (3) your spouse and your newborn within 60 days after                                                                spouse’s effective date will be the
     the date of birth…                                                                                                   first of the month following the
     No other dependents can be added at this time                                                                        newborn’s date of birth
     Note: You have up to one year after the newborn's date                                                               If only enrolling the newborn,
     of birth to add the newborn to coverage if: (1) the child                                                            premium is waived for the first
     is born on or after September 1, 2004, and (2) you                                                                   calendar month if the date of birth is
     have employee and family or employee and child(ren)                                                                  other than the first of the month
     coverage with TRS-ActiveCare at the time of the                                                                      If enrolling the spouse only or
     newborn’s birth.                                                                                                     newborn and spouse, premium is
                                                                                                                          billed for the full month in which
                                                                                                                          coverage begins



30                                                To l l - f r e e    Customer              Service:            1-866-355-5999
If …                                                       Your effective date is…                              Your eligible dependent's          The preexisting
                                                                                                                effective date is…                 condition exclusion
                                                                                                                                                   applies…
As an eligible, but not covered employee, you have a       The newborn’s date of birth                          The newborn’s date of birth        No (for the newborn)
newborn child and choose to enroll:                        Premium is billed for the full month in which        Note: If enrolling a spouse who    Yes (for the employee and
(1) yourself only, or                                      coverage begins                                      was covered under a                spouse, unless enrolling in
(2) you and your spouse, or                                                                                     participating district on the      an HMO option)
(3) you and your newborn, or                                                                                    newborn’s date of birth, the
(4) you, your spouse and your newborn within 60 days                                                            spouse’s effective date will be
after the date of birth…                                                                                        the first of the month following
No other dependents can be added at this time                                                                   the newborn’s date of birth
                                                                                                                Premium is billed for the full
                                                                                                                month in which coverage
                                                                                                                begins

As a covered employee, you adopt a child and choose                                                             The date of adoption or the date No (for the adopted child)
to enroll:                                                                                                      on which the child to be           Yes (for the spouse,
(1) your adopted child only, or                                                                                 adopted is placed with you         unless enrolling in an
(2) your spouse only, or                                                                                        Note: If enrolling a spouse who HMO option)
(3) your spouse and your adopted child within 31 days                                                           was covered under a
after the date of adoption or date on which the child to                                                        participating district on the date
be adopted is placed with you…                                                                                  of adoption or placement of
No other dependents can be added at this time                                                                   adoption, the spouse’s effective
                                                                                                                date will be the first of the
                                                                                                                month following the date of
                                                                                                                adoption or placement of
                                                                                                                adoption
                                                                                                                If only enrolling the newborn,
                                                                                                                premium is waived for the first
                                                                                                                calendar month if the date of
                                                                                                                birth is other than the first of
                                                                                                                the month
                                                                                                                If enrolling the spouse only or
                                                                                                                newborn and spouse, premium
                                                                                                                is billed for the full month in
                                                                                                                which coverage begins


As an eligible, but not covered employee, you adopt a      The date of adoption or date on which the child to   The date of adoption or the date No (for the adopted child)
child and choose to enroll:                                be adopted is placed with you                        on which the child to be           Yes (for the employee and
(1) yourself only, or                                      Premium is billed for the full month in which        adopted is placed with you         spouse, unless enrolling in
(2) you and your spouse, or                                coverage begins                                      Note: If enrolling a spouse who an HMO option)
(3) you and your adopted child, or                                                                              was covered under a
(4) you, your spouse and your adopted child within 31                                                           participating district on the date
days after the date of adoption or the date on which the                                                        of adoption or placement of
child to be adopted is placed with you…                                                                         adoption, the spouse’s effective
No other dependents can be added at this time                                                                   date will be the first of the
                                                                                                                month following the date of
                                                                                                                adoption or placement of
                                                                                                                adoption
                                                                                                                Premium is billed for the full
                                                                                                                month in which coverage
                                                                                                                begins




                                                      www.trs.state.tx.us/trs-activecare                                                                                         31
     If …                                                         Your effective date is…                               Your eligible dependent's          The preexisting
                                                                                                                        effective date is…                 condition exclusion
                                                                                                                                                           applies…
     You become a legal guardian of an eligible dependent                                                               The date the guardianship          Yes (unless enrolling in an
     and choose to enroll the dependent within 31 days after                                                            is granted                         HMO option)
     the date the legal guardianship is granted…                                                                        Premium is waived for the first
                                                                                                                        calendar month if the date of
                                                                                                                        notification is other than the
                                                                                                                        first of the month
     As a covered employee, you add a court-ordered eligible                                                            The date the participating entity Yes (unless enrolling in an
     dependent within 31 days after the entity receives notice                                                          receives notification of the court HMO option)
     of the court order or national medical support notice …                                                            order or national medical
                                                                                                                        support notice
                                                                                                                        Premium is waived for the first
                                                                                                                        calendar month if the date of
                                                                                                                        notification is other than the
                                                                                                                        first of the month
     As an eligible, but not covered employee, you add a                                                                The date the participating entity Yes (unless enrolling in an
     court-ordered eligible dependent within 31 days after                                                              receives notification of the court HMO option)
     the entity receives notice of the court order or national                                                          order or national medical
     medical support notice…                                                                                            support notice
     A court order or national medical support notice is not a                                                          Premium is billed for the full
     special enrollment event for an employee                                                                           month in which coverage
                                                                                                                        begins
     You add an eligible newborn grandchild or another                                                                  The newborn’s date of birth        No
     newborn child who is in a regular parent-child                                                                     Premium is waived for the first
     relationship with you within 31 days after the date of                                                             calendar month if the date of
     birth…                                                                                                             birth is other than the first of
                                                                                                                        the month
     You add an eligible grandchild or another child who is in                                                          First of the month following the   Yes (unless enrolling in an
     a regular parent-child relationship with you within 31                                                             date the participating entity      HMO option)
     days after notifying the entity the child qualifies as a                                                           receives notification that the
     dependent…                                                                                                         child qualifies as a dependent
     As a covered employee, you get married and choose                                                                  The first of the month following   Yes (unless enrolling in an
     to enroll:                                                                                                         the date of marriage               HMO option)
     (1) your spouse only
     (2) your spouse’s eligible children, or
     (3) your spouse and your spouse’s eligible children
     within 31 days after the date of marriage…
     As an eligible, but not covered employee, you get            The first of the month following the date of marriage The first of the month following   Yes (unless enrolling in an
     married and choose to enroll:                                                                                      the date of marriage               HMO option)
     (1) yourself only, or
     (2) you and your spouse, or
     (3) you and your spouse’s eligible children, or
     (4) you, your spouse and your spouse’s eligible children
     within 31 days after the date of marriage…
     No other dependents can be added at this time
     As a covered employee, your dependent child under the                                                              The first of the month following   Yes (unless enrolling in an
     age of 25 obtains a divorce (or annulment) and you                                                                 the date of the divorce (or the    HMO option)
     choose to enroll the child within 31 days after the date                                                           annulment)
     of the divorce (or the annulment)…
     You make changes to coverage due to other special            The first of the month following the event date.      The first of the month following   Yes (unless enrolling in an
     enrollment events within 31 days after the qualifying                                                              the event date                     HMO option)
     event…



32                                                 To l l - f r e e   Customer           Service:          1-866-355-5999
Promptly notify your Benefits Administrator to:
•Terminate TRS-ActiveCare coverage when a child marries or reaches age 25, or
•Terminate TRS-ActiveCare coverage for a spouse upon a divorce.
When coverage is terminated, benefits for expenses incurred after termination will not be available.
If you receive benefits to which you are not entitled, refunds will be requested.

Also remember to notify your Benefits Administrator if you or your dependents have an address change.




When Coverage Ends
                                                                          Can coverage be dropped throughout the plan year?
Your TRS-ActiveCare employee coverage will end:
                                                                          Unless restricted due to participation in an Internal Revenue Code Section 125
• The last day of the month in which your                                 cafeteria plan, an employee can drop employee-only coverage or drop dependent
  employment ends                                                         coverage. You cannot elect to drop coverage retroactively; a future cancellation
• The last day of the month in which you are no longer                    date is required. If coverage is dropped, the individual will not be eligible to re-
                                                                          enroll in TRS-ActiveCare until the next enrollment period. Preexisting condition
  eligible for TRS-ActiveCare coverage (such as your
                                                                          exclusions may apply.
   TRS retirement date)
• When you stop making the required premium                               When is a dependent child no longer eligible for coverage?
                                                                          Coverage for a dependent child terminates at the end of the month in which the
  contribution payments                                                   child turns 25 or marries, whichever occurs first, unless eligible as a disabled
• The last day of the month in which you enter into                       dependent. An unmarried child under age 25 who is employed by a participating
  active, full-time military, naval, or air service except                entity and is a contributing TRS member cannot be covered as a dependent on his
                                                                          or her parent's TRS-ActiveCare coverage. Coverage terminates at the end of the
  as provided under the Uniformed Services
                                                                          month prior to the month in which the child becomes a contributing TRS member.
  Employment and Reemployment Rights Act of 1994                          Refer to page 34 of this booklet for information on how to apply for
  (USERRA) or other applicable law                                        COBRA/continuation coverage for the dependent.
• The last day of the month in which eligibility for
                                                                          If you have a disabled dependent that reaches age 25, your child may be eligible
  COBRA continuation coverage expires                                     for dependent coverage if the child is either mentally retarded or physically
• If a participating entity fails to make all premium                     incapacitated to such an extent as to be dependent on you on a regular basis and
  payments for a period of at least 90 days, or                           the child meets other requirements as determined by TRS. You (and your
                                                                          dependent’s attending physician) must complete a Dependent Child's Statement of
• When the TRS-ActiveCare program is terminated.
                                                                          Disability form to provide satisfactory proof of the disability and dependency. The
                                                                          form must be submitted within 31 days after the date the child turns 25. To avoid
A dependent’s coverage will end:                                          any gap in coverage, the form must be submitted and approved prior to the end of
• When the employee's coverage ends                                       the month in which the child turns 25.

• The last day of the month in which he or she is no                      What happens if an employee or covered dependent enters into
  longer an eligible dependent (for example, your                         military service?
                                                                          If you enter into active, full-time military service, you may continue TRS-ActiveCare
  spouse's coverage will end if you get divorced)
                                                                          coverage while on leave without pay. Employees on military leave without pay will
• If a dependent becomes eligible as an employee who                      be treated in the same manner as other employees on leave without pay in
  is an active contributing TRS member of a                               accordance with the participating entity’s requirements for leave-without-pay
  participating entity                                                    status, for a period not to exceed six months. You and any covered dependents
                                                                          will be eligible for COBRA coverage. The provisions of the Uniformed Services
• The last day of the month in which he or she enters
                                                                          Employment and Reemployment Rights Act of 1994 or other provisions of state
  into active, full-time military, naval, or air service                  law may also apply to provide you and your dependents with continued coverage.
  except as provided under the Uniformed Services                         Under either circumstance, once you return to active employment and meet
  Employment and Reemployment Rights Act of 1994                          eligibility requirements, you can re-enroll for TRS-ActiveCare coverage within 31
                                                                          days. If you return to active employment within the same plan year and choose to
  (USERRA) or other applicable law
                                                                          re-enroll in TRS-ActiveCare, you must select the same plan option in which you
• The last day of the month in which eligibility for                      were previously enrolled. Preexisting conditions will not apply.
  COBRA continuation coverage expires, or
• When you stop paying required contributions for
  dependent coverage.




                                                    www.trs.state.tx.us/trs-activecare                                                                            33
     Continuation of TRS-ActiveCare Coverage (COBRA)                                coverage because of any of the events listed below, they may elect
     The Consolidated Omnibus Budget Reconciliation Act (COBRA)                     to continue group health plan participation. The continued coverage
     passed by the 99th Congress provides that when employees and                   can remain in effect for a maximum period of either 18, 29, or 36
     covered dependents lose their eligibility for group health plan                months, depending on the reason the coverage terminated.



       Events Qualifying for                                 Events Qualifying for                         Events Qualifying for
       18-Month Continuation                                 29-Month Continuation                         36-Month Continuation


       • Loss of eligibility due to reduction of             • Loss of coverage by employee or             • Death of an employee
         employee work hours                                   dependent if determined by the Social       • Divorce or legal separation of an
       • Voluntary employee termination                        Security Administration to be disabled        employee, so long as the spouse was
         including retirement (early or disability)            at any time during the first 60 days          previously enrolled as a covered
       • Employee layoff for economic reasons                  after employment terminated or hours          participant
       • Employee discharge, except for                        were reduced                                • Employee becomes eligible for
         discharge for gross misconduct, or                                                                  Medicare, leaving dependents without
       • Failure of a participating entity to pay            To receive the additional 11 months of          group medical coverage (as in the
         all premiums for at least 90 days                   COBRA continuation coverage, you must           case of an employee who reaches age
                                                             notify your plan administrator (Health Care     65, retires, and begins Medicare
                                                             Service Corporation/Blue Cross and Blue         coverage), or
                                                             Shield of Texas) of the Social Security       • Children who lose coverage due to
                                                             Administration’s determination within 60        plan provisions (for example, reaching
                                                             days of the date of the determination and       the maximum age)
                                                             before the end of the 18-month period of
                                                             COBRA continuation coverage




34                                        To l l - f r e e    Customer        Service:       1-866-355-5999
Eligibility                                                                      When COBRA Coverage Ends
Employees and dependents covered by TRS-ActiveCare the day                       COBRA/continuation coverage ends if:
before the qualifying event are eligible to continue coverage.                   • The COBRA benefits continuation period expires
Dependents not previously enrolled cannot elect to begin coverage.               • Premiums are not paid within 30 days of the due date
                                                                                 • A COBRA participant becomes covered under another group
How to Apply for COBRA
                                                                                   health plan either as an employee, spouse, or dependent, unless
When your group coverage ends, you or your covered dependents
                                                                                   a preexisting condition exclusion prevents the participant from
have 60 days to elect continuation coverage through COBRA. You,
                                                                                   being covered for a specific condition under another group
your spouse, or dependent child must first notify your district/entity's
                                                                                   medical plan
Benefits Administrator. You then will be provided with information on
                                                                                 • A COBRA participant becomes entitled to Medicare benefits, or
your COBRA rights, including forms and general information on the
                                                                                 • TRS-ActiveCare no longer provides group medical coverage for
continuation option. Coverage will be made retroactive to the date of
                                                                                   public education employees.
the qualifying event; however, all back premiums must be paid
before coverage is effective.



   What is the cost for COBRA coverage?
   Any eligible individual electing to continue coverage must pay the full premium rates for
   active employees plus an additional 2% administrative fee. Benefits for COBRA
   participants will be the same as those for active employees. Rates will be based on the
   rates for active employees. If there is a change in TRS-ActiveCare's benefits or rates,
   COBRA participants will receive the new benefits and be charged the new rates.

   Who administers COBRA coverage?
   Billing and eligibility processing for COBRA coverage will be administered by Health
   Care Service Corporation. Blue Cross and Blue Shield of Texas is a Division of Health
   Care Service Corporation. Please call 1-888-541-7107 if you have any questions
   regarding COBRA/continuation coverage.




                                                www.trs.state.tx.us/trs-activecare                                                                   35
     How to File a Medical Claim
     You or your provider must submit and Blue Cross and Blue Shield of Texas must receive all claims for benefits
     under TRS-ActiveCare within 12 months of the date on which you received the services or supplies. Claims
     not submitted and received by Blue Cross and Blue Shield of Texas within this 12-month period will not be
     considered for payment of benefits.




     Who files claims?                                                                     Written agreements between Blue Cross and Blue Shield of Texas
     When you receive treatment or care from a network provider (or                        and other providers may require payment directly to them.
     non-network provider who is a ParPlan provider), you will not be                      However, if the benefit payments are for claims from providers with
     required to file claims. The provider will submit the claims directly                 no written agreement with Blue Cross and Blue Shield of Texas,
     to Blue Cross and Blue Shield of Texas for you.                                       Blue Cross and Blue Shield of Texas may choose to pay either you
                                                                                           or your provider. If you receive payment from Blue Cross and Blue
     You may be required to file your own claims when you receive
                                                                                           Shield of Texas, it will be your responsibility to settle your account
     treatment or care from a non-network provider who is not a
                                                                                           with your provider.
     ParPlan provider. At the time services are provided, inquire whether
     the provider will file claims for you.                                                If allowed by law, any benefits available to you, if unpaid at your
                                                                                           death, will be paid to your surviving spouse, as beneficiary. If there
     Benefit payments will be made directly to network or contracting
                                                                                           is no surviving spouse, then the benefits will be paid to your estate.
     providers when they bill Blue Cross and Blue Shield of Texas.




        To file a medical claim, follow these steps:
                                                Claim forms are available from your Benefits Administrator, or you can download a claim form from
        1 Get a claim form                      the Web site by logging on to www.trs.state.tx.us/trs-activecare. Use a separate claim form for each
                                                individual; do not combine expenses for family members on one claim form.
                                                Complete all information requested on the claim form. Any missing information, especially the items
                                                listed below, will cause a delay in processing your claim.
                                                • Patient's name
                                                • Subscriber number, including the alpha prefix (ISD)
        2 Complete the claim form
                                                • Correct address
                                                • Diagnosis (preferably indicated by your provider on an itemized bill)
                                                • Date of injury, illness, or pregnancy
                                                • Whether the patient has other group health insurance coverage
                                                Attach an itemized bill to the completed claim form. An itemized bill includes the following
                                                information that is critical to prompt processing of your claim:
                                                • Name and address of the provider providing the services or supplies
                                                • Date of service
        3 Attach an itemized bill               • Type of service
                                                • Charges for each service
                                                • Patient's name
                                                • Diagnosis
                                                Keep a copy of the claim form and itemized bills for your records.
                                                Send the claim form and itemized bills to: Blue Cross and Blue Shield of Texas, P.O. Box 660044,
        4 Mail the claim form and
                                                Dallas, TX 75266-0044. (The address also appears on the form.) Do not send the claim form to TRS.
          itemized bills
                                                This will only delay processing.
        5 You will receive an                   The EOB will confirm if the expense is covered by TRS-ActiveCare and is eligible for payment. If so,
          Explanation of Benefits                you or the provider will receive a check. If your claim is denied, the EOB will state the reasons why.
          (EOB) after the claim is              You must file and Blue Cross and Blue Shield of Texas must receive claims for expenses within 12
          processed                             months after the date the expense is incurred.


36                                             To l l - f r e e   Customer          Service:         1-866-355-5999
To assist providers in filing your claims, you should always carry your TRS-ActiveCare ID card with you.
Need a claim form?
Network providers and ParPlan providers will file claims for you. However, if you use a non-network provider for your medical care, you will
need to complete a claim form available from your Benefits Administrator or Customer Service. You can also download a claim form from
the Web site by logging on to www.trs.state.tx.us/trs-activecare. Instructions for completing and mailing the claim are on the form.




Receipt of Claims                                                          Request for Reconsideration of Claim Determination
A claim will not be considered received for processing until Blue Cross    You have the right to seek and obtain a full and fair review of any
and Blue Shield of Texas actually receives the claim at the proper         determination of a claim, any determination of a request for inpatient
address and with all of the required information. If the claim is not      preauthorization, extended care and home infusion therapy
complete, Blue Cross and Blue Shield of Texas will return it. On claims    preauthorization, or any other determination made by the plan
that need further information for proper processing, Blue Cross and        regarding your TRS-ActiveCare benefits. If you believe all or part of your
Blue Shield of Texas may contact either you or the provider for the        benefits were incorrectly denied and want to obtain a review of the
additional information. The claim will be processed when Blue Cross        benefit determination, you must:
and Blue Shield of Texas receives all the requested information.
                                                                           1. Call Customer Service (1-866-355-5999) or submit by U.S. mail a
Interpretation of TRS-ActiveCare Provisions                                written request for reconsideration to Blue Cross and Blue Shield of
TRS has full and complete authority to make decisions regarding            Texas. The request must contain your name, the participant's name,
TRS-ActiveCare plan provisions and to determine questions of eligibility   your group and subscriber numbers, and the claim you want reviewed.
and benefits.
                                                                           2. The written request must contain the questions and comments you
Blue Cross and Blue Shield of Texas has been given authority by TRS to     have concerning the determination, and you must submit all additional
determine whether:                                                         information (especially medical information) that has a bearing on why
• Services, care, treatment or supplies are medically necessary            you believe the determination was incorrect.
• Surgery is cosmetic or reconstructive
                                                                           Blue Cross and Blue Shield of Texas will review your claim on the basis
• Charges are allowable
                                                                           of the comments, questions, and information received in the request for
• Surgery, medical treatment, services or drugs are
                                                                           review, together with any other available information.
   experimental/investigational
                                                                           You will be notified in writing of Blue Cross and Blue Shield of Texas'
Review of Claim Determinations
                                                                           decision and the reasons for it within 60 days of Blue Cross and Blue
Claims Processing: When a claim is submitted correctly and received
                                                                           Shield of Texas' receipt of the request for review. If you are not in
by Blue Cross and Blue Shield of Texas, it will be processed to
                                                                           agreement with a Blue Cross and Blue Shield of Texas decision based
determine if, and in what amount, benefits should be paid. Blue Cross
                                                                           on medical necessity, you may request a second medical review by
and Blue Shield of Texas has authority to interpret and determine
                                                                           Blue Cross and Blue Shield of Texas.
benefits in accordance with TRS-ActiveCare provisions. Some claims
take longer to process because they require information not provided       In the event your Request for Reconsideration is denied by Blue Cross
with the claim, such as medical records or operative reports.              and Blue Shield of Texas, you may further appeal to the Teacher
                                                                           Retirement System of Texas (your plan sponsor) at the address below:
If a Claim Is Denied or Not Paid in Full: On occasion, all or part of
your claim may be denied. There are a number of reasons why the            TRS-ActiveCare Grievance Administrator
claim may be denied or not paid in full. First read the Explanation of     Teacher Retirement System of Texas
Benefits and then review this booklet to see whether you understand        1000 Red River Street, Austin, TX 78701
the reason for the determination. If you have additional information       The appeal to TRS must be submitted in writing and accompanied by
that you believe could change the payment decision, call Customer          supporting written documents. Your written appeal must be submitted
Service at 1-866-355-5999 or write to Blue Cross and Blue Shield of        by U.S. Mail and be postmarked or received by TRS within 60 days
Texas at P.O. Box 660044, Dallas, TX 75266-0044 to request a               from the date of the Blue Cross and Blue Shield of Texas letter notifying
review of the decision.                                                    you of their decision on your Request for Reconsideration. Upon receipt
                                                                           of a written appeal, TRS will advise you of any procedures available to
                                                                           you under TRS Rules and Laws.


                                              www.trs.state.tx.us/trs-activecare                                                                        37
     Subrogation, Reimbursement and Third Party                                     If it becomes necessary for the plan to enforce this provision by
     Recovery Provision                                                             initiating any action against the employee or covered person, then the
     When this Provision Applies: If you, your spouse, one of your                  employee or covered person agrees to pay the plan’s attorney’s fees
     dependents, or anyone who receives benefits under this health plan is          and costs associated with the action regardless of the action outcome.
     injured and entitled to receive money from any source, including but
                                                                                    TRS has the sole authority to interpret the terms of this provision in its
     not limited to any party’s liability or auto insurance and
                                                                                    entirety and reserves the right to make changes as it deems necessary.
     uninsured/underinsured motorist proceeds, then the benefits provided
     or to be provided by TRS-ActiveCare are secondary, not primary, and            If the employee or covered person takes no action to recover any
     will be paid only if you fully cooperate with the terms and conditions of      money from any source, the employee or covered person agrees to
     TRS-ActiveCare.                                                                allow the plan to initiate its own direct action for reimbursement.

     As a condition of receiving benefits under TRS-ActiveCare, the                 Coordination of Benefits
     employee or covered person agrees that acceptance of benefits is               TRS-ActiveCare includes a Coordination of Benefits (COB) provision
     constructive notice of this provision in its entirety and agrees to            that determines how benefits will be paid when you or your
     reimburse the plan 100% of benefits provided without reduction for             dependent is covered by more than one group health plan. When
     attorney’s fees, costs, comparative negligence, limits of collectability or    you have other group medical coverage (through your spouse’s
     responsibility, or otherwise. If the employee or covered person retains        employer, for example), your TRS-ActiveCare benefits may be
     an attorney, then the employee or covered person agrees to only retain         combined with others to pay covered charges (including
     one who will not assert the Common Fund or Made Whole Doctrines.               prescriptions under ActiveCare 1). The COB provision eliminates
     Reimbursement shall be immediately upon collection of any sum(s)               duplicate payments for the same medical expenses. TRS-ActiveCare
     recovered regardless of its legal, financial or other sufficiency. If the      may coordinate benefits for the prescription drug program under the
     injured person is a minor, any amount recovered by the minor, the              ActiveCare 2 and ActiveCare 3 plans. Coordination of Benefits does
     minor’s trustee, guardian, parent or other representative, shall be            not apply to any individual policy you may have.
     subject to this provision regardless of state law and/or whether the
     minor’s representative has access or control of any recovery funds.            Under the COB provision, the plan that pays first is called the
                                                                                    primary plan. The secondary plan typically makes up the difference
     The employee or covered person agrees to sign any documents
                                                                                    between the primary plan's benefit and the covered charge. When
     requested by TRS-ActiveCare, including but not limited to
                                                                                    one plan does not have a COB provision, that plan is always
     reimbursement and/or subrogation agreements the plan or its agent(s)
                                                                                    considered primary and always pays first. COB payments do not
     may request. Also, the employee or covered person agrees to furnish
                                                                                    always total 100% of charges.
     any information as requested by the plan or its agent(s). Failure or
     refusal to execute such agreements or furnish information does not
     preclude the plan from exercising its rights to subrogation or obtaining
     full reimbursement. Any settlement or recovery received shall first be
     deemed for reimbursement of medical expenses paid by the plan. Any
     excess after 100% reimbursement of the plan may be divided up
     between the employee or covered person and their attorney if
     applicable. The employee or covered person agrees to take no action
     that in any way prejudices the rights of the plan.



38                                           To l l - f r e e   Customer         Service:    1-866-355-5999
How to determine which plan is primary                                      • The plan that covers a person as an active employee (or that
These rules are applied in the order in which they appear until one           employee’s dependent) is primary over the plan that covers the
resolves the issue.                                                           employee as a laid-off or retired employee (or that employee’s
• The plan without a COB provision is considered primary. If both plans       dependent). If both plans do not agree on the order of benefits, this
   have COB, then the plan covering the patient as an employee rather         rule does not apply.
   than a dependent is primary.                                             • The plan that covers a person as an active employee (or that
• If a child is covered under both parents’ plans, the plan of the parent     employee’s dependent) is primary over the plan that covers the
  whose birth date is earlier in the calendar year is primary. If both        employee (or that employee’s dependent) under COBRA/continuation
  parents have the same birthday, the plan which has covered one                coverage. If both plans do not agree on the order of benefits, this
  parent longer is primary. If the other plan does not have this                rule does not apply.
  provision regarding birthdays, then the rules in that plan determine      If none of these rules apply, the plan that has covered the patient
  the order of benefits.                                                    longer will be primary. Special rules apply when you are covered by
• Dependent children of divorced or separated parents receive               TRS-ActiveCare and Medicare. Generally, TRS-ActiveCare is the primary
  benefits payments in this order from the plan of the:                      plan if you are an active employee or a dependent of an active
  • Parent with custody                                                     employee, and Medicare is secondary. Special rules may apply to
  • Stepparent with custody                                                 participants with End Stage Renal Disease (ESRD).
  • Parent without custody
  The parent with financial responsibility for the child’s health care
                                                                               How are COB benefits paid?
  expenses under a court decree is primary. The other parent’s plan            TRS-ActiveCare will pay the difference between the allowable
  would be secondary. In the case of joint custody with no specific            amount and the benefit paid by the primary plan, not to exceed the
  requirements to provide health care expenses, the birthday rule              amount TRS-ActiveCare would have paid in the absence of any
                                                                               other coverage
  as described above would apply.
                                                                               How are benefits coordinated for a newborn within the
                                                                               first 31 days after birth?
                                                                               A newborn child is automatically covered for the first 31 days after
                                                                               the date of birth. The plan of the parent whose birth date is earlier
                                                                               in the calendar year is primary.



  How is the primary plan determined for COB purposes between a husband and wife?
  When both plans have a Coordination of Benefits (COB) provision, the following chart shows how the primary plan is determined for the
  spouse. The chart assumes that the husband and wife are both active employees and not covered by COBRA.

  If the TRS-ActiveCare                  …and the other plan is                …and expenses                        …then
  covered employee is:                   sponsored by:                         are for:                             TRS-ActiveCare is:

  The husband                            Wife's employer                       Husband                              Primary

  The husband                            Wife's employer                       Wife                                 Secondary
  The wife                               Husband's employer                    Husband                              Secondary
  The wife                               Husband's employer                    Wife                                 Primary



                                               www.trs.state.tx.us/trs-activecare                                                                      39
     Online Resources




     Web Site Features                                                       The chart below highlights online capabilities and features for
     You can access helpful information and administrative forms from        TRS-ActiveCare participants. To access online information, go to
     the Blue Cross and Blue Shield of Texas and Medco Web sites             www.trs.state.tx.us/trs-activecare, select Medical and
     through the TRS-ActiveCare Web site, www.trs.state.tx.us/trs-           Pharmacy Benefits, then select the plan's Web site. Many of
     activecare. Blue Cross and Blue Shield of Texas and Medco are           the most frequently requested features appear directly on the
     solely responsible for the accuracy and security of information         TRS-ActiveCare home page.
     maintained on or through their Web sites.

                                                                 ActiveCare 1, ActiveCare 2 and ActiveCare 3
      Teacher Retirement System of Texas (TRS)
                                                                 Blue Cross and Blue Shield of Texas and Medco
      Health Benefits                                            Health Benefits                         Pharmacy Benefits
      Provider Locator                                           Provider Finder                         Pharmacy Benefits
      Frequently Asked Questions                                 Enrollment Guide                        Retail Pharmacy Locator
      Enrollment Guide                                           Plan Comparison Tutorial                Drug Name Search
      Enrollment Application and Change Form                     Forms                                   Copays
      Application Tutorial                                       Benefits Booklet                        What are Possible Alternatives
                                                                 Healthy Living Information              Preferred Drug List
                                                                 Blue Access for Members (view claims)   View Formulary Alternatives
                                                                 Contact Information                     Prescription Management Programs
                                                                                                         Maintenance Drug List




40                                       To l l - f r e e   Customer    Service:     1-866-355-5999
Blue Access for Members
With Blue Access for Members you can:
• Check the status of a claim
• Confirm who is covered under your plan
• View and print detailed claim history and information
  (Explanation of Benefits)
• Opt-out of receiving paper copies of your Explanation of Benefits
• Locate a physician in your network that meets your needs
• Sign up to receive email notifications of new claim activity
• Request a new or replacement ID card or print a temporary ID card

You also have access to health and wellness information from Mayo
Clinic. Complete a health risk assessment, research prescription
drugs or test your knowledge of a variety of health topics – it's all in
Blue Access for Members.


Get more than you expect by logging on to Blue Access for
Members
                                                                           How to Find Blue Access for Members
Blue Cross and Blue Shield of Texas not only administers health care       1. Go to www.trs.state.tx.us/trs-activecare
coverage for TRS-ActiveCare plan participants, but it also offers a        2. Select Medical Benefits
variety of online health care information. Find out if your claim has
                                                                           3. Under ActiveCare 1, 2, 3, click Medical Administered by
been paid, print a temporary ID card or locate a doctor or hospital
that meets your needs - it's all in Blue Access for Members.                  Blue Cross and Blue Shield of Texas
                                                                           4. Select Blue Access for Members
Blue Cross and Blue Shield of Texas has also contracted with Mayo
Clinic to bring you health and wellness information you can trust.         To register for Blue Access for Members, you'll need your group
Through Mayo Clinic, you can:                                              and member identification number, found on your TRS-ActiveCare
• Complete a health risk assessment                                        ID card. Upon authentication, you'll be asked to create a user
• Take a quiz to test your knowledge of a specific health topic            name and password that you'll use for all future visits to Blue
• Learn about hundreds of health conditions
                                                                           Access for Members.
• Participate in a self-care program tailored to help you stay healthy
                                                                           Use Blue Access for Members from 6 a.m. to 3 a.m. (Central Time)
                                                                           Monday through Friday and 6 a.m. to 12 a.m. (Central Time)
                                                                           Saturdays and Sundays.




                                              www.trs.state.tx.us/trs-activecare                                                              41
     Glossary of Terms



     These definitions apply to all TRS-ActiveCare benefits unless                reasonable expectation of cure or improvement of sickness or injury.
     specifically limited.                                                        Custodial care is care which is not a necessary part of medical
                                                                                  treatment for recovery, and shall include, but not be limited to,
     Actively-at-Work Date: The actively-at-work date is the date the
                                                                                  helping a person walk, bathe, dress, eat, prepare special diets, and
     employee of a participating district/entity starts to work.
                                                                                  take medication.
     Allowable Amount: The allowable amount is the maximum amount
                                                                                  Deductible: The amount of out-of-pocket expense that must be
     that will be paid by TRS-ActiveCare for a medical service or supply,
                                                                                  paid for health care services by the covered person before becoming
     except for emergency treatment by a non-network provider in a
                                                                                  payable by the health plan.
     network facility within 48 hours of an emergency (see page 13).
     The allowable amount is determined by Blue Cross and Blue Shield             Emergency: An emergency is the sudden onset of a medical
     of Texas and is based on the negotiated rates with providers; Blue           condition manifesting itself by acute symptoms of sufficient severity,
     Cross and Blue Shield of Texas rates for the same service by                 including severe pain, that would lead a prudent layperson
     providers in the same geographic area with similar training,                 possessing an average knowledge of medicine and health, to believe
     experience and facilities; or any other recognized source.                   that the person's condition, sickness or injury is of such a nature
                                                                                  that failure to get immediate care could result in:
     Benefits Administrator: The person employed by a district/entity
                                                                                  • Placing the person’s health in serious jeopardy
     who can help employees enroll in various benefits plans and make
                                                                                  • Serious impairment to bodily functions
     changes to their coverage.
                                                                                  • Serious dysfunction of any bodily organ or part
     Coinsurance: A participant's share of covered services and                   • Serious disfigurement, or
     supplies, not counting the deductible or copayments. It is usually a         • In the case of a pregnant woman, serious jeopardy to the health of
     percentage of the allowable amount. For example, if the                         the fetus.
     coinsurance amount is "80/20" that means that TRS-ActiveCare
                                                                                  TRS-ActiveCare covers medical emergencies wherever they occur.
     pays 80% and you pay 20% of the allowable amount for the eligible
                                                                                  In case of emergency, call 911 or go to the nearest emergency
     charges.
                                                                                  room. If you are treated by a non-network provider in a network
     Copayment (Copay): The set amount you pay for certain medical                hospital during the first 48 hours of your emergency, benefits will be
     services and prescription drugs at the time of service. Copays do            paid at the network level based on the billed amount instead of the
     not apply to deductibles or out-of-pocket maximums.                          allowable amount. Ambulance services will be paid up to the
     Creditable Coverage: Prior health coverage under various plans               allowable amount.
     including, but not limited to, group health plans, individual health         Experimental/Investigational: A drug, device or medical treatment
     policies, Medicare, and Medicaid.                                            or procedure is experimental or investigational if:
     Crisis Stabilization Unit: An institution which is appropriately             • The drug or device has not received U.S. Food and Drug
     licensed and accredited as a crisis stabilization unit or facility for the      Administration approval both for marketing and as safe and
     provision of mental health care services to persons who are                     efficacious at the time the drug or device is furnished; or
     demonstrating an acute, demonstrable psychiatric crisis of moderate          • The drug, device, medical treatment or procedure, or the patient
     to severe proportions.                                                          informed consent document utilized with the drug, device,
                                                                                     treatment or procedure, was reviewed and approved by the
     Custodial Care: Services and supplies, including room and board                 treating facility's Institutional Review Board or other body serving
     and other institutional services, provided primarily to assist in               a similar function, or if federal law requires such review and
     activities of daily living and to maintain life and/or comfort with no          approval; or


42                                         To l l - f r e e   Customer        Service:     1-866-355-5999
• Reliable evidence shows that the drug, device or medical                  • Has a hospital utilization review plan, and
  treatment or procedure is the subject of on-going phase I, II, or         • Is not, other than incidentally, a skilled nursing facility, nursing
  III clinical trials or under study to determine its maximum                 home, custodial care home, health resort, spa, sanitarium,
  tolerated dose, its toxicity, its safety, its efficacy, or its efficacy     place for rest, place for the aged, place for the treatment of
  compared with the standard means of treatment or diagnosis; or              chemical dependency, hospice, or place for the provision of
• Reliable evidence shows that the consensus of opinion among                 rehabilitative care.
  experts regarding the drug, device or medical treatment or                Hospital Admission: The period between entry into a hospital as a
  procedure is that further studies or clinical trials are necessary        bed patient and the time of discharge. If a patient is admitted to and
  to determine its maximum tolerated dose, its toxicity, its safety,        discharged from a hospital within a 24-hour period but is confined
  its efficacy or its efficacy as compared with the standard means          as a bed patient in a bed accommodation during the period of time
  of treatment or diagnosis.                                                confined in the hospital, the admission shall be considered a hospital
Reliable evidence, as used in this definition, shall mean only              admission. Bed patient means confinement in a bed
published reports and articles in the authoritative medical and             accommodation located in a portion of a hospital which is designed,
scientific literature; the written protocol or protocols used by the        staffed and operated to provide acute, short-term hospital care on a
treating facility or the protocols of another facility studying             24-hour basis; the term does not include confinement in a portion of
substantially the same drug, device or medical treatment or                 the hospital designed, staffed and operated to provide long-term
procedure; or the written informed consent used by the treating             institutional care on a residential basis.
facility or by another facility studying substantially the same drug,       Marriage and Family Therapy: Includes professional therapy
device or medical treatment or procedure.                                   services to individuals, families, or married couples, singly or in
Although a physician or other health care provider may have                 groups, and involves the professional application of family systems
prescribed treatment, and the services or supplies may have been            theories and techniques in the delivery of therapy services to those
provided as the treatment of last resort, such services or supplies         persons. The term includes the evaluation and remediation of
still may be considered to be experimental/investigational within           cognitive, affective, behavioral, or relational dysfunction within the
this definition.                                                            context of marriage or family systems. TRS-ActiveCare does not
                                                                            provide coverage for marriage and family therapy.
Hospital: A short-term acute care facility which:
• Is duly licensed as a hospital by the state in which it is located and    Out-of-Pocket Maximum: Your share of eligible expenses
  meets the standards established for such licensing, and is either         incurred during a plan year excluding the deductible and copays
  accredited by the Joint Commission on Accreditation of Health             (medical and prescription drug). After you reach the out-of-pocket
  Care Organizations or is certified as a hospital provider under           maximum, TRS-ActiveCare pays 100% of the allowable amount for
  Medicare                                                                  covered charges for the rest of the plan year. Deductibles and
• Is primarily engaged in providing inpatient diagnostic and                copays do not apply to the out-of-pocket maximum.
  therapeutic services for the diagnosis, treatment, and care of            Preauthorization penalties and billed charges exceeding the Blue
  injured and sick persons by or under the supervision of physicians        Cross and Blue Shield of Texas allowable amount also do not apply
  for compensation from its patients                                        to the out-of-pocket maximum.
• Has organized departments of medicine and major surgery and
                                                                            Participant: A person who is enrolled in TRS-ActiveCare.
  maintains clinical records on all patients
• Provides 24-hour nursing services by or under the supervision of a        Plan Year: The plan year for TRS-ActiveCare begins September 1
  registered nurse                                                          and ends August 31.


                                            www.trs.state.tx.us/trs-activecare                                                                       43
     Psychiatric Day Treatment Facility: An institution appropriately           Any such facility must be licensed, certified, or approved as a
     licensed and accredited by the Joint Commission on Accreditation of        chemical dependency treatment center by the appropriate state
     Health Care Organizations as a psychiatric day treatment facility for      agency and be accredited by the Joint Commission on Accreditation
     the provision of mental health care services to participants for time      of Health Care Organizations.
     periods not to exceed eight hours in any 24-hour period.
                                                                                Telemedicine: The use of interactive audio, video or other
     Treatment must be in lieu of hospitalization and certified in writing      electronic media (excluding telephone or fax machines) to deliver
     by the attending physician.                                                health care. The term includes the use of electronic media for
                                                                                diagnosis, consultation, treatment, transfer of medical data, and
     Residential Treatment Center for Children and Adolescents: An
                                                                                medical education.
     institution appropriately licensed and accredited by the Joint
     Commission on Accreditation of Health Care Organizations or the
     American Association of Psychiatric Services for Children and/or is
     approved by Blue Cross and Blue Shield of Texas or INROADS
     Behavioral Health Services as a residential treatment center for
     certain mental health care services for emotionally disturbed
     children and adolescents.

     Special Enrollment Event: An event as defined by the Health
     Insurance Portability and Accountability Act of 1996 (HIPAA) that
     may provide a special enrollment period for individuals and
     dependents when there is a loss of other coverage or a gain of
     additional dependents.

     Substance Abuse Facility: An institution which provides a program
     for the treatment of chemical dependency following a written
     treatment plan approved and monitored by a physician affiliated with
     a hospital under a contractual agreement with an established
     system for patient referral.




44                                        To l l - f r e e   Customer        Service:   1-866-355-5999
Notices



Health Insurance Portability and Accountability Act                       The preexisting condition waiting period is reduced by any creditable
                                                                          coverage (prior coverage under various plans including, but not
In 1996 Congress passed the Health Insurance Portability and
                                                                          limited to, group health plans, individual health policies, Medicare,
Accountability Act of 1996 (HIPAA). HIPAA impacts group health
                                                                          and Medicaid). You may obtain a certificate of creditable coverage
plans by improving the availability and portability of health coverage.
                                                                          from a prior plan sponsor or health insurance issuer. Should you
HIPAA also requires that group health plan participants be given the
                                                                          disagree with the length of creditable coverage determined by
following notices.
                                                                          TRS-ActiveCare, you have the right to appeal that determination and
• Notice of Enrollment Rights – If you are declining enrollment for       provide evidence of creditable coverage.
yourself or your dependents (including your spouse) because of
                                                                          For further information, contact your Benefits Administrator.
other health insurance coverage, you may in the future be able to
enroll yourself or your dependents in this plan, provided that you        *Special rules apply to newborns covered by TRS-ActiveCare; see
request enrollment within 31 days after your other coverage ends.         box on page 16 for more information.
In addition, if you have a new dependent as a result of marriage,
birth, adoption, or placement for adoption, you may be able to enroll
yourself and your dependents, provided that you request enrollment
within 31 days after the marriage, birth*, adoption, or placement for
adoption.

• Notice of Preexisting Condition Exclusion – Under HIPAA, a
“preexisting condition” is a condition for which medical advice,
diagnosis, care, or treatment was recommended or received within the
six-month period ending on the enrollment date in a health plan.

Your plan may deny benefits for a preexisting condition during a
12-month waiting period beginning on your enrollment date.
(If you do not enroll in a timely manner, the maximum waiting period
is 12 months from the date coverage begins.) A preexisting
condition exclusion does not apply to a pregnancy or to a newborn
child or adopted child under age 18 who becomes covered within
31 days of birth* or adoption. A genetic condition without advice,
care, or treatment is not a preexisting condition.

The existence of a preexisting condition will be determined using
information obtained relating to an individual’s health status before
his or her enrollment date.




                                             www.trs.state.tx.us/trs-activecare                                                                   45
     Notice of Privacy Practices                                                How TRS May Use and Disclose Your Protected
     This notice describes how medical information about you may be             Health Information
     used and disclosed and how you can get access to this information.         Certain Uses and Disclosures Do Not Require Your Written
                                                                                Permission
     Please review it carefully.
                                                                                TRS may use and disclose your protected health information without
     Federal law requires the Teacher Retirement System of Texas (TRS)
                                                                                your written permission (an authorization) for the following reasons:
     to protect the privacy of your health information. Your protected
     health information is information that:                                    • For treatment. TRS does not directly participate in decisions
     • Identifies you; and                                                      about what kind of health treatment you should receive. TRS also
     • TRS created or received about:                                           does not maintain your current medical records. However, TRS may
       • Your past, present or future health condition;                         disclose your protected health information for treatment purposes.
       • The health care you receive; or                                        For example, TRS may disclose your protected health information if
       • The payment for this health care.                                      your doctor asks that TRS disclose the information to another doctor
                                                                                to help in your treatment.
     The effective date of this notice is April 14, 2003. Texas law
     already makes your member information, including your protected            • For payment. Here are two examples of how TRS might use or
     health information, confidential. Therefore, TRS is not changing the       disclose your protected health information for payment. TRS or one of
     way that it protects your information.                                     its business associates, who are discussed below, may use or disclose
                                                                                your information to prepare a bill for medical services to you or another
     On April 14, 2003, the new rights and other terms in this notice will
                                                                                person or company responsible for paying the bill. The bill may include
     automatically apply. You do not need to do anything to get
                                                                                information that identifies you, the health services you received, and
     privacy protection for your health information.
                                                                                why you received those services. The second example is that TRS or its
     Federal law requires that TRS provide you with this notice about its       business associates could use or disclose your protected health
     privacy practices and its legal duties regarding your protected health     information to collect your premium payments.
     information. This notice explains how, when, and why TRS uses and
                                                                                • For health care operations. TRS may provide your protected
     discloses your protected health information. By law, TRS must follow
                                                                                health information to its accountants, attorneys, consultants, and
     the privacy practices that are described in the most current privacy
                                                                                others in order to make sure TRS is complying with the laws that
     notice.
                                                                                affect it. For example, your protected health information may be
     TRS reserves the right to change its privacy practices and the terms       given to people looking at the quality of the health care you received.
     of this notice at any time. Changes will be effective for all of your      Another example of health care operations is TRS using and sharing
     protected health information that TRS maintains. If TRS makes an           this information to manage its business and perform its
     important change that affects what is in this notice, TRS will mail you    administrative activities.
     a new notice within 60 days of the change. This notice is on the
                                                                                • To you or your personal representative. TRS may provide your
     TRS Web site, and TRS will post any new notice on its Web site at
                                                                                protected health information to you, a person representing or authorized
     www.trs.state.tx.us.
                                                                                by you, or any person that you tell TRS in writing is acting on your
                                                                                behalf. For this purpose, a person acts on your behalf by being involved
                                                                                in your health care or in the payment for your health care.




46                                            To l l - f r e e   Customer    Service:     1-866-355-5999
• When federal, state or local law, judicial or administrative          All Other Uses And Disclosures Require Your Prior Written
proceedings, or law enforcement requires a disclosure. For              Authorization
example, TRS may disclose your protected health information:            For any other use or disclosure of your protected health information,
  • To a federal or state criminal law enforcement agency that asks     TRS must have your written permission (an authorization). You may
    for the information for a law enforcement purpose;                  cancel (revoke) your written permission at any time. Revoking your
  • To the Texas Attorney General to collect child support or to        written permission will not affect a use or disclosure of your
    ensure health care coverage for your child;                         protected health information that TRS already made based on your
  • In response to a subpoena if the TRS Executive Director             written permission.
    determines that you will have a reasonable opportunity to
                                                                        Your Rights
    contest the subpoena;
                                                                        • The Right to Request Limits on Uses and Disclosures of Your
  • To a governmental entity, an employer, or a person acting on
                                                                        Protected Health Information
    behalf of the employer, to the extent that TRS needs to share
                                                                        You can ask that TRS limit how it uses and discloses your protected
    the information to perform TRS’s business; and
                                                                        health information. TRS will consider your request but is not
  • If required by other federal, state, or local law.
                                                                        required to agree to it. If TRS agrees to your request, TRS will put
• For specific government functions. TRS may disclose                   the agreement in writing and will follow the agreement unless you
protected health information of military personnel and veterans in      need emergency treatment, and the information that you asked be
certain situations. TRS may also disclose protected health              limited is needed for your emergency treatment. You cannot limit
information for national security purposes, such as protecting the      the uses and disclosures that TRS is legally required to make.
President of the United States or conducting intelligence operations.
                                                                        • The Right to Choose How TRS Sends Protected Health
• Business associates. TRS has contracts with companies                 Information to You
(business associates) that help TRS in its business of providing        You can ask that TRS send information to you to an alternate
health care coverage. For example, several companies assist TRS         address (for example, sending information to your work address
with the TRS-Care and TRS-ActiveCare programs: Aetna, Blue Cross        rather than your home address) or by alternate means (for example,
and Blue Shield of Texas, Medco Health Solutions, Inc. and Gabriel,     courier service instead of U.S. mail) only if not changing the address
Roeder, Smith & Company. TRS may disclose your protected health         or the way TRS communicates with you could put you in physical
information to its business associates so that they can perform the     danger. You must make this request in writing. You must be
services that TRS has asked them to do. To protect your health          specific about where and how to contact you. TRS must agree to
information, however, TRS requires that these companies follow the      your request only if:
same rules that are set out in this notice.                                • You clearly tell TRS that sending the information to your usual
                                                                             address or in the usual way could put you in physical danger;
• Executor or administrator. TRS may disclose your protected
                                                                            and
health information to the executor or administrator of your estate.
                                                                          • You tell TRS a specific alternative address or specific alternative
• Health-related benefits. TRS or one of its business associates            means of sending protected health information to you.
may contact you to provide appointment reminders. They may also
contact you to give you information about treatment alternatives or
other health benefits or services that may be of interest to you.




                                              www.trs.state.tx.us/trs-activecare                                                                  47
     • The Right to See and Get Copies of Your Protected                             • The date of the disclosure or use;
     Health Information                                                              • The person or entity that received the protected health
     You can look at or get copies of your protected health information                information;
     that TRS has or that a business associate maintains on TRS’s behalf.            • A description of the information disclosed; and
     You must make this request in writing. If your protected health                 • Why TRS disclosed or used the information.
     information is not on file at TRS and TRS knows where the
     information is maintained, TRS will tell you where you can ask to see         If TRS disclosed your protected health information because you gave
                                                                                   TRS written permission to disclose the information, instead of telling
     and get copies of your information.
                                                                                   you why TRS disclosed the information, TRS will give you a copy of
     If you request copies of your protected health information, TRS can           your written permission.
     charge you a fee for each page copied, for the labor involved in
     copying the information, and for postage if you request that the              You can get a list of disclosures for free every 12 months. If you
     copies be mailed to you. Instead of providing the protected health            request more than one list during a 12-month period, TRS can
     information you request, TRS may provide you with a summary or                charge you for preparing the list, including charges for copying,
     explanation of the information, but only if you agree in advance to:          labor, and postage to process and mail each additional list. These
       • Receive a summary or explanation instead of the detailed                  fees will be the same as the fees allowed under the Texas Public
         protected health information; and                                         Information Act. TRS will tell you in advance of the fees it will
       • Pay the cost of preparing the summary or explanation.                     charge. You can withdraw or change your request at any time.
     The fee for the summary or explanation will be in addition to any             • The Right to Correct or Update Your Protected
     copying, labor, and postage fees that TRS may require. If the total           Health Information
     fees will exceed $40, TRS will tell you in advance. You can withdraw          If you believe that there is a mistake in your protected health
     or change your request at any time.                                           information or that a piece of important health information is
     • The Right to Get a List of TRS’s Uses and Disclosures of Your               missing, you can ask TRS to correct or add the information. You
     Protected Health Information                                                  must request the correction or addition in writing. Your letter must
     You have the right to get a list of TRS’s uses and disclosures of your        tell TRS what you think is wrong and why you think it is wrong. TRS
     protected health information. By law, TRS is not required to create a         will respond to your request within 60 days of receiving it. TRS can
     list that includes any uses or disclosures:                                   extend this deadline one time by an additional 30 days. If TRS
         • To carry out treatment, payment, or healthcare operations;              extends its response time, it must tell you in writing the reasons for
         • To you or your personal representative;                                 the delay and the date by which TRS will respond.
       • Because you gave your permission;                                         Because of the technology used to store information and laws requiring
       • For national security or intelligence purposes;                           TRS to retain information in its original text, TRS may not be able to
       • To corrections or law enforcement personnel; or                           change or delete information, even if it is incorrect. If TRS decides that
       • Before April 14, 2003.                                                    it should correct or add information, it will add the correct or additional
     TRS will respond to your request within 60 days of receiving it. TRS          information to your records and note that the new information takes the
     can extend this deadline one time by an additional 30 days. If TRS            place of the old information. The old information may remain in your
     extends its response time, TRS will tell you in writing the reasons for       record. TRS will tell you that the information has been added or
     the delay and the date by which TRS will provide the list. The list will      corrected. TRS will also tell its business associates that need to know
     include:                                                                      about the change to your protected health information.


48                                          To l l - f r e e   Customer         Service:    1-866-355-5999
TRS will deny your request if your request is not in writing or does      All complaints must be in writing.
not have a reason why the information is wrong or incomplete.             You can also send a written complaint to the Office for Civil Rights, U.S.
TRS will also deny your request if the protected health information is:   Department of Health and Human Services: Region VI, Office for Civil
  • Correct and complete;                                                 Rights, U.S. Department of Health and Human Services, 1301 Young
  • Not created by TRS; or                                                Street, Suite 1169, Dallas, Texas 75202, FAX (214) 767-0432, and
  • Not part of TRS’s records.                                            e-mail at OCRComplaint@hhs.gov. Finally, you can send a written
                                                                          complaint to the Texas Office of the Attorney General by mail at
TRS will send you the denial in writing. The denial will say why your
                                                                          P.O. Box 12548, Austin, Texas, 78711-2548, or by telephone at
request was denied and explain your right to send TRS a written
                                                                          (800) 806-2092. TRS will not retaliate against you if you file a
statement of why you disagree with TRS’s denial. TRS’s denial will also
                                                                          complaint.
tell you how to complain to TRS or the Secretary of the Department of
Health and Human Services. If you send TRS a written statement of         More Information
why you disagree with the denial, TRS can file a written reply to your    If you want more information about this notice, how to exercise your
statement. TRS will give you a copy of any reply.                         rights, or how to file a complaint, please contact the TRS Telephone
                                                                          Counseling Center at 1-800-223-8778. TDD users should call
If you file a written statement disagreeing with the denial, TRS must
                                                                          1-800-841-4497. Additional information is also available on the
include your request for an amendment, your written statement of
                                                                          TRS Web site at www.trs.state.tx.us.
disagreement, and any reply when TRS discloses the protected
health information that you asked to be changed. Or TRS can               Women's Health and Cancer Notice
choose to give out a summary of that information with a disclosure        The Women’s Health and Cancer Rights Act of 1998 requires this
of the protected health information that you asked to be changed.         notice. This Act is effective for plan year anniversaries on or after
Even if you do not send TRS a written statement explaining why you        October 21, 1998. This benefit may already be included as part of
disagree with the denial, you can ask that your request and TRS’s         your coverage.
denial be attached to all future disclosures of the protected health
                                                                          In the case of a covered person receiving benefits under their plan
information that you wanted changed.
                                                                          in connection with a mastectomy and who elects breast
• The Right to Get This Notice                                            reconstruction, coverage will be provided in a manner determined in
You can get a paper copy of this notice on request.                       consultation with the attending physician and the patient for:
                                                                          1. Reconstruction of the breast on which the mastectomy was
• The Right to File a Complaint
                                                                             performed;
If you think that TRS has violated your privacy rights concerning your
                                                                          2. Surgery and reconstruction of the other breast to produce a
protected health information, you can file a written complaint with
                                                                             symmetrical appearance; and
the TRS Privacy Officer by mailing your complaint to:
                                                                          3. Prostheses and treatment of physical complications at all stages
Privacy Officer                                                              of the mastectomy, including lymphedemas.
Teacher Retirement System of Texas
                                                                          Deductibles and coinsurance amounts will be the same as those
1000 Red River Street
                                                                          applied to other similarly covered medical services, such as surgery
Austin, Texas 78701
                                                                          and prostheses.




                                               www.trs.state.tx.us/trs-activecare                                                                      49
     Continuation Coverage Rights Under COBRA                                    If you are an employee, you will become a qualified beneficiary if you
     Introduction                                                                will lose your coverage under the Plan because one of the following
     You are receiving this notice because you have recently become covered      qualifying events happens:
     under TRS-ActiveCare, your Employer’s group health plan (the Plan).         (1) Your hours of employment are reduced;
     This notice contains important information about your right to COBRA        (2) Your employment ends for any reason other than your gross
     continuation coverage, which is a temporary extension of coverage                misconduct; or
     under the Plan. The right to COBRA continuation coverage was created        (3) Your participating entity fails to pay all premiums for at least 90 days.
     by a federal law, the Consolidated Omnibus Budget Reconciliation Act of
                                                                                 If you are the spouse of an employee, you will become a qualified
     1985 (COBRA). COBRA continuation coverage may be available to you
                                                                                 beneficiary if you will lose your coverage under the Plan because any of
     and to other members of your family who are covered under the Plan
                                                                                 the following qualifying events happens:
     when you would otherwise lose your group health coverage. Contact
                                                                                 (1) Your spouse dies;
     your Employer to determine if you are eligible for COBRA continuation
                                                                                 (2) Your spouse’s hours of employment are reduced;
     coverage.
                                                                                 (3) Your spouse’s employment ends for any reason other than his or her
     This notice generally explains:                                                 gross misconduct;
     • COBRA continuation coverage,                                              (4) Your spouse becomes enrolled in Medicare (Part A, Part B, or both);
     • When it may become available to you and your family, and                  (5) You become divorced or legally separated from your spouse; or
     • What you need to do to protect the right to receive it.                   (6) Your spouse’s participating entity fails to pay all premiums for at
                                                                                     least 90 days.
     This notice gives only a summary of your COBRA continuation coverage
     rights. For more information about your rights and obligations under the    Your dependent children will become qualified beneficiaries if they will
     Plan and under federal law, you should either contact the Plan              lose coverage under the Plan because any of the following qualifying
     Administrator or review the Benefit Booklet or Certificate of Coverage      events happens:
     provided to you by your Plan.                                               (1) The parent-employee dies;
                                                                                 (2) The parent-employee’s hours of employment are reduced;
     The Plan Administrator of the Plan is named by the Employer or by the
                                                                                 (3) The parent-employee’s employment ends for any reason other than
     group health plan. Either the Plan Administrator or a third party named
                                                                                      his or her gross misconduct;
     by the Plan Administrator is responsible for administering COBRA
                                                                                 (4) The parent-employee becomes enrolled in Medicare (Part A,
     continuation coverage. Contact your Plan Administrator for the name,
                                                                                      Part B, or both);
     address, and telephone number of the party responsible for
                                                                                 (5) The parents become divorced or legally separated;
     administering your COBRA continuation coverage.
                                                                                 (6) The child stops being eligible for coverage under the Plan as a
     COBRA Continuation Coverage                                                      “dependent child”; or
     COBRA continuation coverage is a continuation of Plan coverage when         (7) The parent-employee’s participating entity fails to pay all premiums
     coverage would otherwise end because of a life event known as a                  for at least 90 days.
     “qualifying event.” Specific qualifying events are listed later in this
                                                                                 If the Plan provides health care coverage to retired employees, the
     notice. COBRA continuation coverage must be offered to each person
                                                                                 following applies:
     who is a “qualified beneficiary.” A qualified beneficiary is someone who
                                                                                 Sometimes, filing a proceeding in bankruptcy under Title 11 of the
     will lose coverage under the Plan because of a qualifying event.
                                                                                 United States Code can be a qualifying event. If a proceeding in
     Depending on the type of qualifying event, employees, spouses of
                                                                                 bankruptcy is filed with respect to your employer, and that bankruptcy
     employees, and dependent children of employees may be qualified
                                                                                 results in the loss of coverage of any retired employee covered under
     beneficiaries. Under the Plan, generally most qualified beneficiaries who
                                                                                 the Plan, the retired employee is a qualified beneficiary with respect to
     elect COBRA continuation coverage must pay for COBRA continuation
                                                                                 the bankruptcy. The retired employee’s spouse, surviving spouse, and
     coverage. Contact your Employer and/or COBRA Administrator for
                                                                                 dependent children will also be qualified beneficiaries if bankruptcy
     specific information for your Plan.
                                                                                 results in the loss of their coverage under the Plan.

50                                         To l l - f r e e   Customer     Service:       1-866-355-5999
The Plan will offer COBRA continuation coverage to qualified                Disability extension of 18-month period of
beneficiaries only after the Plan Administrator has been notified           continuation coverage
that a qualifying event has occurred.                                       If you or anyone in your family covered under the Plan is
The Employer must notify the Plan Administrator within 30 days when         determined by the Social Security Administration to be disabled at
the qualifying event is:                                                    any time during the first 60 days of COBRA continuation coverage
• The end of employment;                                                    and you notify the Plan Administrator in a timely fashion, you and
• The reduction of hours of employment;                                     your entire family can receive up to an additional 11 months of
• The death of the employee;                                                COBRA continuation coverage, for a total maximum of 29 months.
• In the event of retired employee health coverage, commencement of         You must make sure that your Plan Administrator is notified of the
   a proceeding in bankruptcy with respect to the employer; or              Social Security Administration’s determination within 60 days of
• The enrollment of the employee in Medicare (Part A, Part B, or both).     the date of the determination and before the end of the 18-month
                                                                            period of COBRA continuation coverage. Contact your Employer
For the other qualifying events (divorce or legal separation of the
                                                                            and/or the COBRA Administrator for procedures for this notice,
employee and spouse or a dependent child’s losing eligibility for
                                                                            including a description of any required information or
coverage as a dependent child), you must notify the Plan
                                                                            documentation.
Administrator. The Plan requires you to notify the Plan
Administrator within 60 days of the later of (1) the date on which          Second qualifying event extension of 18-month period of
the qualifying event occurs; and (2) the date coverage would have           continuation coverage
been lost as a result of the qualifying event. Contact your                 If your family experiences another qualifying event while receiving
Employer and/or the COBRA Administrator for procedures for this             COBRA continuation coverage, the spouse and dependent children in
notice, including a description of any required information or              your family can get additional months of COBRA continuation coverage,
documentation.                                                              up to a maximum of 36 months. This extension is available to the
                                                                            spouse and dependent children if the former employee dies, enrolls in
Once the Plan Administrator receives notice that a qualifying event has
                                                                            Medicare (Part A, Part B, or both), or gets divorced or legally separated.
occurred, COBRA continuation coverage will be offered to each of the
                                                                            The extension is also available to a dependent child when that child
qualified beneficiaries. For each qualified beneficiary who elects COBRA
                                                                            stops being eligible under the Plan as a dependent child.
continuation coverage, COBRA continuation coverage will begin on the
date that Plan coverage would otherwise have been lost.                     In all of these cases, you must make sure that the Plan
                                                                            Administrator is notified of the second qualifying event within 60
COBRA continuation coverage is a temporary continuation of coverage.
                                                                            days of the second qualifying event. Contact your Employer and/or
COBRA continuation coverage may last for up to 36 months when the
                                                                            the COBRA Administrator for procedures for this notice, including a
qualifying event is:
                                                                            description of any required information or documentation.
• The death of the employee;
• The enrollment of the employee in Medicare (Part A, Part B, or both);     If You Have Questions
• Your divorce or legal separation; or                                      If you have questions about your COBRA continuation coverage, you
• A dependent child losing eligibility as a dependent child.                should contact the Plan Administrator or you may contact the nearest
                                                                            Regional or District Office of the U. S. Department of Labor’s Employee
When the qualifying event is the end of employment, reduction of the
                                                                            Benefits Security Administration (EBSA). Addresses and phone numbers
employee’s hours of employment, or failure of the participating entity to
                                                                            of Regional and District EBSA Offices are available through EBSA’s Web
pay all premiums for at least 90 days, COBRA continuation coverage
                                                                            site at www.dol.gov/ebsa.
lasts for up to 18 months. There are two ways in which this 18-month
period of COBRA continuation can be extended.                               In order to protect your family’s rights, you should keep the Plan
                                                                            Administrator informed of any changes in the addresses of family
                                                                            members. You should also keep a copy, for your records, of any notices
                                                                            you send to your Plan Administrator.
                                                                                                                                    Rev.01/2004 (TRS09/04)


                                               www.trs.state.tx.us/trs-activecare                                                                            51
     Sample ID Cards




                                                                                                                                    TEACHER RETIREMENT SYSTEM   OF   TEXAS


                                                                                                                                   www.trs.state.tx.us/trs-activecare

                                                                             Name JANE DOE
                                                          Group Name
                                                                             Identification No. ISD123456789                       Group No.          085000
                                                                                                                                   BC Plan       400     BS Plan 900
                                                                             Coverage Date 09-01-04
                                                                                                                                   Primary Care Copay                   $25
                                                         Group Number        Network No.        PTROA                              Specialist Copay                    $35
                                                                                                                                   Preventive Care Copay                $25


                                                                                                                                                           ActiveCare 2
                                                          Alpha Prefix


                                                         Plan Names          Customer Service or claims information, call 1-866-355-5999.
                                                                             Claims filing address, refer to your TRS-ActiveCare benefits booklet.

                                                                             Network coverage is available through participating network providers. Non-Network
                                                                             services will be covered at a lower level. To identify participating network providers
                                                                             outside Texas, call 1-800-810-BLUE (1-800-810-2583).
                                                                                                                                      TEACHER RETIREMENT SYSTEM   OF   TEXAS
                                                                             Some services must be precertified before you receive them. Your
                                                       Copay Information     TRS-ActiveCare benefits booklet has more information. To precertify, call
                                                                             1-800-441-9188.
                                                                                                                                www.trs.state.tx.us/trs-activecare

                                                                              Name JANE DOE
                                                                             For precertification and referral of mental health care and chemical
                                                                             dependency treatment, call 1-800-528-7264.
                                                                              Identification No. ISD123456789                      Group No.          085000
                                                                             Retail pharmacy benefits are administered by Medco Health. The BIN# is
                                                                                                                                   to Plan 400
                                                                             610014.Present this card to a retail network pharmacyBCreceive benefits. BS Plan          900
                                                       Customer Service       Coverage Date Desk number
                                                                             The Pharmacy Help 09-01-04 for pharmacists to call is 1-800-922-1557.
                                                                                                                                   Primary Care Copay                  $20
                                                                             Blue Cross and Blue Shield of Texas, a Division of Health Care Service
                                                           Numbers                               PTROA                            Specialist Copay
                                                                             Corporation, a Mutual Legal Reserve Company, an Independent Licensee of
                                                                              Network No.
                                                                             the Blue Cross and Blue Shield Association provides administrative claims
                                                                                                                                                                       $30
                                                                                                                                  Preventive Care Copay
                                                                             payment services only and assumes no financial risk with respect to claims.               $20
                                                                                                                                   Emergency Care Copay                $50

                                                                                                                                                           ActiveCare 3




                                                                               Customer Service or claims information, call 1-866-355-5999.
                                                                               Claims filing address, refer to your TRS-ActiveCare benefits booklet.

                                                                               Network coverage is available through participating network providers. Non-Network
                                                                               services will be covered at a lower level. To identify participating network providers
                                                                               outside Texas, call 1-800-810-BLUE (1-800-810-2583).

                                                                               Some services must be precertified before you receive them. Your
                                                                               TRS-ActiveCare benefits booklet has more information. To precertify, call

       Customer Service                     INROADS® Behavioral Health                   Web Site
                                                                               1-800-441-9188.

                                                                               For precertification and referral of mental health care and chemical
                                                                               dependency treatment, call 1-800-528-7264.

       1-866-355-5999                       1-800-528-7264                               www.trs.state.tx.us/trs-activecare
                                                                               Retail pharmacy benefits are administered by Medco Health. The BIN# is
                                                                               610014.Present this card to a retail network pharmacy to receive benefits.
                                                                               The Pharmacy Help Desk number for pharmacists to call is 1-800-922-1557.

       8 a.m. - 8 p.m. (Central Time)       8 a.m. - 5 p.m. (Central Time)     Blue Cross and Blue Shield of Texas, a Division of Health Care Service
                                                                               Corporation, a Mutual Legal Reserve Company, an Independent Licensee of
                                                                               the Blue Cross and Blue Shield Association provides administrative claims
                                                                               payment services only and assumes no financial risk with respect to claims.
       Monday through Friday                Monday through Friday


       Preauthorization                     BlueCard PPO Access
       1-800-441-9188                       1-800-810-BLUE (2583)
       6 a.m. - 6 p.m. (Central Time)       24 hours, seven days a week
       Monday through Friday




52                                      www.trs.state.tx.us/trs-activecare

				
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