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

Division of Human Resources

San Luis Valley HMO

Return to FY08 Medical Page Go to New FY09 Medical Page SLVHMO Description Plan Details & Exclusions Enroll/Change

Summary of Benefits for the San Luis Valley HMO Plan
Note: This is only a summary, not a contract. For more details, see the "Description" above and consult the "Plan Details & Exclusions" above to determine the exact 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	Total Premium (monthly / annually)	State Pays... (monthly / annually)	Employee Pays... (monthly / annually)
	Employee only $344.84/ $4138.08 Employee + Spouse $752.80/ $9033.60 Employee + Child(ren) $616.80/ $7401.60 Employee + Family $990.76/ $11,889.12	Employee only $285.84 / $3430.08 Employee + Spouse $491.18 / $5894.16 Employee + Child(ren) $442.84 / $5314.08 Employee + Family $663.96 / $7967.52	Employee only $59.00 / $708.00 Employee + Spouse $261.62 / $3139.44 Employee + Child(ren) $173.96 / $2087.52 Employee+ Family $326.80 / $3921.60
Deductibles	none, co-pay for services
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 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	PCP⁽³⁾ - $30 co-pay Specialist - $50 co-pay
	Out-of-Network	No Out-of-Network benefits
Routine Office Visit	In-Network	PCP⁽³⁾ - $30 co-pay Specialist - $50 co-pay
	Out-of-Network	No Out-of-Network benefits
In-Patient Hospital	In-Network	$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	$200 co-pay per procedure
	Out-of-Network	No Out-of-Network benefits

(1) Family 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, not a contract. Consult the "Plan Details & Exclusions" (also called a Summary Plan Description) to determine the exact terms and conditions of coverage.

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

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For more information about Benefits contact the DPA Benefits Unit.

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