Allowable Amount - The maximum amount determined by the health plan to be eligible for consideration of payment for a particular service, supply or procedure.
Allowable Charge - The maximum amount a health plan will reimburse a doctor or hospital for a given service.
Annual Deductible - The amount of eligible expenses you are required to pay annually before reimbursement by your health plan begins.
Annual Limit - An insurance plan may limit the dollar amount it will pay during one year for a certain treatment or service, or for all benefits provided in a year.
Annual Out-of-Pocket - The maximum amount, per year, you are required to pay out of your own pocket for covered health care services.
Coinsurance - A percentage of an eligible expense that you are required to pay for a service covered by your health plan.
Coordination of Benefits (COB) - An arrangement where, if you or your dependents are covered under more than one group health plan, the plans work together to coordinate reimbursement for the medical services you received.
Copayment - A fixed dollar amount you are required to pay for a covered service at the time you receive care.
Covered Service - A service that is covered according to the terms in your health care policy.
Deductible - A fixed amount of the eligible expenses you are required to pay before reimbursement by your health plan begins.
Dependent - A person, other than the member/subscriber (generally a spouse or child), who receives health care coverage under the member's/subscriber's policy.
Drug Formulary - A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.
Exclusions - Specific medical conditions or circumstances that are not covered under a health plan.
Explanation of Benefits (EOB) - The form sent to you after a claim has been processed by your health plan. The EOB explains the actions taken on the claim such as the amount paid, the benefit available, and reasons for denying payment and the claims appeal process.
Generic Substitute - A prescription drug that is the generic equivalent of a drug listed on your health plan's formulary.
In-Network - Covered services provided or ordered by your primary care physician (PCP) or another network provider referred by your PCP.
Inpatient Services - Services provided when a member/subscriber is registered and treated as a bed patient in a health care facility such as a hospital.
Maximum Allowance - A fixed amount that providers agree to accept as payment in full for a particular covered service.
Out-of-Network - Services not provided, ordered or referred by your primary care physician (PCP).
Out-of-Pocket Maximum - The maximum amount you have to pay for eligible expenses under your health plan during a defined benefit period.
Outpatient Services - Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.
Pre-Determination - The process by which a member/subscriber or their primary care physician (PCP) notifies the health plan, in advance, of plans for the member/subscriber to undergo a course of care such as a hospital admission or a complex diagnostic test.
Preferred Drug List - A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a health plan's prescription drug list are automatically covered under that plan.
Your coverage will begin 28 days after the first day of employment, on the first of the following month.
No you do not have to take the district’s insurance. In lieu of medical insurance, the district will provide you with an In-Hospital Indemnity Plan.
Yes, you will have one card with information on it for Blue Cross Blue Shield of Texas (medical) and Prime Therapeutics (prescription).
You may enroll family members during Open Enrollment or if you have a qualified status change. A qualified status change is defined as such: marriage, divorce, birth of a child, adoption or loss of coverage with spouse. Status changes must be reported to the Benefits Office within 31 days of the qualifying event.
The pre-existing condition clause will not apply if proof of 12 months of creditable coverage is provided for new hires and 18 months of creditable coverage for open enrollment enrollees under the age of 19.
The Hospital Indemnity Plan is an Amarillo ISD “Opt-Out” plan. If you have insurance with your spouse you may elect this coverage to allow you to use their plan as your primary insurance. There are no cards issued with this plan. Claim forms are available through the Amarillo ISD Benefits Office.
Yes, Prime Therapeutics is the prescription plan for Amarillo ISD. There is not a separate card to get your prescriptions filled. You are eligible for the plan through both the Amarillo ISD BSA PPO and Amarillo ISD BSA HDHP. You are not eligible for the prescription plan through the Hospital Indemnity Plan.
Contact Prime Specialty at 1-877-627-6337.
No, you will not receive vision cards. There are no cards needed to access this plan. You will need to make an appointment with an in-network provider and tell them you are a VSP member. You will need to give them your employee identification number for them to access your benefits. For example, if your employee identification number is 1234 you will need to add five zeros in front to make a 9-digit number, 000001234. Your provider will then be able to verify your benefits online through the VSP system. VSP Customer Service: 800-877-7195.
You may enroll yourself and family members during two times of the year; either during Open Enrollment or if you have a qualified status change. A qualified status change is defined as such: marriage, divorce, birth of a child, adoption or loss of coverage with spouse. Status changes must be reported to the Benefits Office within 31 days of the qualifying event. If the employee does not enroll upon hire, but enrolls during Open Enrollment, they will be subject to a six-month waiting period.
No, you will not receive dental cards. There are no cards needed to access this plan. You may use any provider in the area. You will need to take an Amarillo ISD Dental Claim Form with you to your appointment. Claim forms are available through the Personnel Office or on our Amarillo ISD website under Employee Benefits. You will pay for your appointment and submit the claim form with receipt to the Benefits Office within 90 days of paying the provider. Please see the plan specifications for detailed reimbursement information.
You may carry any child up to age 26. The child is not required to be a full-time student. Once your child turns 26 or obtains his/her own insurance, please contact the Benefits Office to take him/her off.