Editor's note: As the Laboratory continues planning for open enrollment in November and a new health-care plan provider beginning in January 2004, the Daily Newsbulletin will publish news stories about the various new plans being offered. The Select EPO is one of the new plans being offered by United Healthcare. Future stories will discuss in detail other plan options and subjects related to health care. Blue Cross Blue Shield New Mexico will continue as the Lab's health-care provider through Dec. 31.

Select EPO plan details are similar to HMO-type plans

The Select Exclusive Provider Organization (EPO) Plan for University of California Laboratory employees and retirees replaces the Blue Cross Blue Shield New Mexico HMO. It will function in the same way as the current HMO with some minor exceptions.

The United Healthcare EPO plan is available to all UC Lab employees and participating, immediate family members. UC Lab employees who work in Nevada, Washington, D.C. and Carlsbad also are eligible for the EPO plan.

The following are some key elements of the Select EPO plan:

• The Select EPO has a 90/10 percent co-insurance for certain types of medical expenses, which is similar to the current HMO with Blue Cross Blue Shield New Mexico. Examples of the types of medical expenses that are paid at 90 percent, with the employee paying 10 percent are diagnostic work such as blood work, MRIs, CT scans, etc.
• The UC employee/retiree co-insurance payments, such as those noted above, apply toward an annual $150 deductible per individual with a maximum deductible of $450 per family.
• There is a $20 co-pay for regular doctor visits, which is the same as the current plan.
• Co-payments do not apply toward the deductible. Note: Co-pays are for visits to a doctor. Co-insurance is for expenses beyond regular doctor visits.
• Co-payments do apply toward out-of-pocket limit of $2,000 per individual and $6,000 per family.
• Hospitalization, ambulance and diagnostic procedures have a 90/10 co-insurance after the deductible is met. So for example, if a procedure costs $1,000, the plan pays $900 and the employee/retiree pays $100 if they have already met their deductible. If the deductible has not been met, the same procedure, would cost the employee a $150 deductible, plus $85 for the co-insurance. The insurance company would pay $765.
• Preventive physical exams have a $20 co-payment except for children under age 2 (no co-payment for children from birth to 2 years of age). Preventive physical exams for children are much more than an annual physical and can include immunizations.
• Well baby care and preventive inoculations are no charge until age 2.
• There is a $75 co-pay for emergency room visits. This is identical to the Lab's current plan. If admitted to a hospital, there is not a co-payment. The charges are covered under the plan at 90 percent, with the employee/retiree paying 10 percent.

Chiropractic care is covered as long as the doctor is a member of the American Chiropractic Association, for a $20 co-payment per visit with a maximum of 20 visits per year.

Acupuncture is covered as long as the doctor is certified, for a co-payment of $20 per visit with a maximum of 20 visits per year.

New services provided through the Select EPO Plan

Note: The $20 co-payment is for a doctor visit that yields a diagnosis in the case of hearing aids. Everything else is a $20 co-pay.

• Hearing aids are covered every 36 months at 50 percent up to a $2,000 maximum, limited to one standard hearing aid per ear, either analog or digital.
• Speech therapy is covered for a maximum of 20 visits.
• Outpatient occupational therapy is covered for a maximum of 20 visits.
• Physical therapy is covered for a maximum of 20 visits.
• Surgery for the morbidly obese is covered (bariatric/duodenal switch).
• Christian Science practitioners are covered (These are doctors for members that are Christian Scientists and do not believe in traditional medical care).

Service area

• The EPO will be offered in New Mexico, Nevada and Washington, D.C., for both UC Laboratory and California employees and retirees.
• The networks available to these employees will be the local or national EPO networks. United Healthcare is working on expanding its networks in New Mexico and having great success in contracting with local area physicians.

Prescription drugs

The new provider for prescription drugs is Medco.

Retail prescription drugs - One co-payment for up to a 31-day supply during each one-month period. Note: The present prescription plan provides a 30-day supply.

• Generic $15 co-payment
• Preferred brand $30 co-payment
• Nonpreferred brand $45 co-payment

Mail-order prescription drugs - One co-payment for up to a 31-day supply. Two co-payments for a 32-90-day supply. Note: The present prescription plan provides a 30-day supply.

• Generic two co-payments or $30.
• Preferred Brand two co-payments or $60.
• Non Preferred Brand two co-payments or $90.

If a member or doctor requests a brand-name drug when a generic equivalent is available, members pays generic co-payment plus cost difference between the brand name and generic. The member pays the cost difference between selecting a brand-name drug over an available generic (drug).

More information about plan options for 2004 is available at the HealthCare: Pathways to Change Web site. The Pathways Web site also has a link to United Healthcare's Los Alamos Web page.