Colorado Dept of Personnel and Administration (DPA) - Division of Human Resources (DHR)

Division of Human Resources

NEW FY09 San Luis Valley HMO Information

Return to FY09 Medical Page Return to FY08 Medical Page FY09 SLVHMO Description Enroll/Change

Summary of FY09 Benefits for the San Luis Valley HMO Plan
Note: This is only a summary, not a contract. For more details, see the "FY09 Description" above to determine further terms and conditions of coverage.

Availability	By county	Alamosa, Conejos, Costilla, Mineral, Rio Grande, and Saguache counties
Plan Administrator	San Luis Valley HMO	slvhmo.com	719-589-3696 / 1-800-475-8466
Type of Plan	Health Maintenance Organization	There are NO Out-of- Network benefits.	See Provider Directory for In-Network physicians
Premiums - FY09	Total Premium (monthly / annually)	State Pays... (monthly / annually)	Employee Pays... (monthly / annually)
	Employee only $398.34/ $4780.08 Employee + Spouse $871.16/ $10,453.92 Employee + Child(ren) $723.56/ $8682.72 Employee + Family $1186.34/ $14,239.08	Employee only $340.26 / $4083.12 Employee + Spouse $565.44/ $6785.28 Employee + Child(ren) $499.80 / $5997.60 Employee + Family $782.92 / $9395.04	Employee only $58.08/ $696.96 Employee + Spouse $305.72/ $3668.64 Employee + Child(ren) $223.76 / $2685.12 Employee+ Family $403.42 / $4841.04
Deductibles - New for FY09	Individual - $250 Family⁽¹⁾ - $750
Out-of-Pocket Maximums	In-Network	Individual - $1000 + co-pays Family⁽¹⁾- $3000 + co-pays
	Out-of-Network	No Out-of-Network benefits
Prescriptions	Lesser of 30-day supply or 100-unit dose	90-day supply (mail order) ⁽²⁾	Find your meds on approved drug list (from Rx Solutions)
	Formulary Generic - $10 co-pay Formulary Brand Name - $25 co-pay Non-formulary Brand Name or Generic - $50 co-pay Injectables/specific listed high-cost oral meds - 20% co-insurance All subject to $100 per member prescription deductible before co-pay applies	Two co-pays required for 90-day supply of maintenance drugs through mail order. All subject to $100 per member prescription deductible before co-pay applies	For more prescription information, contact Customer Service at 719-589-3696 / 1-800-475-8466
Preventive Care	In-Network	Co-pays apply even BEFORE deductible has been met. PCP⁽³⁾ - $30 co-pay Specialist - $50 co-pay
	Out-of-Network	No Out-of-Network benefits
Routine Office Visit	In-Network	Co-pays apply only after deductible has been met. PCP⁽³⁾ - $30 co-pay Specialist - $50 co-pay
	Out-of-Network	No Out-of-Network benefits
In-Patient Hospital	In-Network	Co-pays apply only after deductible has been met. $250 co-pay per day; up to max of 4 days per admission co-pay
	Out-of-Network	No Out-of-Network benefits
Out-Patient Surgery	In-Network	Co-pays apply only after deductible has been met. $200 co-pay per procedure
	Out-of-Network	No Out-of-Network benefits

(1) Family deductibles and out-of-pocket maximum amounts apply to Employee + Spouse, Employee + Child(ren) & Employee + Family levels.
(2) For more information on Mail Order prescriptions, contact SLVHMO Customer Service at 719-589-3696 / 1-800-475-8466.
(3) Primary Care Physician
Note: This is only a summary the FY09 San Luis Valley HMO plan information, not a contract. Contact San Luis Valley HMO at 719-589-3696 / 1-800-475-8466 with specific questions about treatments, prescriptions, doctors and hospitals.

More San Luis Valley HMO Information
Medicare Part D Notice for San Luis Valley HMO Plan

Related Links
Premiums (now includes new FY09 Premiums)
Who is my human resources contact?
Insurance Companies’ Phone Numbers
What do “Pre-tax” and “After tax” mean?
Instructions for Online Enrollment
HealthLine
Glossary of Insurance Terms
Forms

Return to Benefits Home Page

For more information about Benefits contact the DPA Benefits Unit.

Email comments to: DPA Benefits

These documents may be presented in PDF format, which requires the Adobe® Reader.

tttt