BlueCross BlueShield of Texas - Select Choice Plan Benefits
PPO Select Choice - Outline of Coverage
|PPO Network||BlueChoice of Texas PPO Network||N/A|
|Lifetime Maximum Benefit||Unlimited|
Per individual, per calendar year. No individual will be required to satisfy the more than the individual deductible amount toward the family deductible amount.
$250 per individual / $750 per family1
$500 per individual / $1,500 per family1
$1,000 per individual / $3,000 per family1
$1,500 per individual / $4,500 per family1
$2,500 per individual / $7,500 per family1
$3,500 per individual / $10,500 per family1
$5,000 per individual / $15,000 per family1
$10,000 per individual / $30,000 per family1
|Office Visits||100% after $25 copay||70%|
|Preventive Care Services
||100% after $25 copay||70%|
The level of coverage provided by the plan after the calendar year deductible has been satisfied.
|Out-of-Pocket Expense Limit
The amount of money an individual pays toward covered hospital and medical expenses during any one calendar year. Does not include deductible.
|Family Out-of-Pocket Expense Limit||$6,000||$12,000|
|Outpatient Prescription Drug Benefit||You Pay||Select Choice Pays|
Per person per calendar year
Up to a 30-day supply.
|Preferred Drugs||$30 co-payment2||100%|
|Non-Preferred Drugs||$45 co-payment2||100%|
Up to a 90-day supply of maintenance drugs is available through home delivery.
|Preferred Drugs||$60 co-payment2||100%|
|Non-Preferred Drugs||$90 co-payment2||100%|
|Calendar Year Maximum||There is a $3,000 calendar year maximum for each member whether or not benefits are received at a participating pharmacy, non-participating pharmacy, or through the mail service prescription drug program.|
|Benefits for covered services are provided at either the Eligible Charge or the Maximum Allowance. Consult the Policy for definitions and your financial responsibility.|
| 1 Does not apply to out-of-pocket expense limit.
2 Deductible does not apply.
PRE-EXISTING CONDITIONS LIMITATION
Pre-existing Conditions are those health conditions which were diagnosed or treated by a Provider during the 12 months prior to the coverage effective date, or for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis or treatment. Any Pre-existing Condition will be subject to a waiting period of 365 days.
Blue Cross Blue Shield of Texas may change premium rates only if they do so on a class basis for all DB-43 HCSC policies. Premiums can be changed based on age, sex, and rating area.
Coverage under this Policy will be terminated for non-payment of premium. Blue Cross Blue Shield of Texas can refuse to renew this Policy only for the following reasons:
A. If all Policies bearing form number DB-43 HCSC are not renewed, written notice will be provided at least 90 days before coverage is discontinued. Furthermore, you may convert to any other individual policy Blue Cross Blue Shield of Texas offer to the individual market.
B. In the event of fraud or an intentional misrepresentation of material fact under the terms of the coverage, written notice will be given at least 30 days before coverage is discontinued.
|Hospitalization, Services, and supplies which are not Medically Necessary; Services or supplies that are not specifically mentioned in this Policy; Services or supplies for any illness or injury arising out of or in the course of employment for which benefits are available under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits except where not required by law; Services or supplies that are furnished to you by the local, state, or federal government; Services and supplies for any illness or injury occurring on or after your Coverage Date as a result of war or an act of war; Services or supplies that do not meet accepted standards of medical or dental practice; Investigational Services and Supplies, including all related services and supplies; Custodial Care Service; Routine physical examinations, unless specifically stated in this Policy; Services or supplies received during an Inpatient stay when the stay is primarily related to behavioral, social maladjustment, lack of discipline, or other antisocial actions which are not specifically the result of Mental Illness; Cosmetic Surgery and related services and supplies, except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases; Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar coverage; Charges for failure to keep a scheduled visit or charges for completion of a Claim form; Personal hygiene, comfort, or convenience items commonly used for other than medical purposes, such as air conditioners, humidifiers, physical fitness equipment, televisions, and telephones; Special braces, splints, specialized equipment, appliances, ambulatory apparatus, battery controlled implants, except as specifically mentioned in this Policy; Eyeglasses, contact lenses, or cataract lenses and the examinations for prescribing or fitting of glasses or contact lenses or for determining the refractive state of the eye, except as specifically mentioned in this Policy; Treatment of flat foot conditions and the prescription of supportive devices for such conditions and the treatment of subluxations of the foot or routine foot care; Immunizations, unless otherwise stated in this Policy; Maintenance Occupational Therapy, Maintenance Physical Therapy, and Maintenance Speech Therapy; Speech Therapy when rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome), attention disorder, conceptual handicap, or mental retardation; Hearing aids or examinations for the prescription or fitting of hearing aids; Diagnostic Service as part of routine physical examinations or check-ups, premarital examinations, determination of the refractive errors of the eyes, auditory problems, surveys, case finding, research studies, screening, or similar procedures and studies, or tests which are Investigational, unless otherwise specified in this Policy; Procurement or use of prosthetic devices, special appliances, and surgical implants which are for cosmetic purposes, or unrelated to the treatment of a disease or injury; Services and supplies provided for the diagnosis and/or treatment of infertility including, but not limited to, Hospital services, Medical Care ,therapeutic injection, fertility and other drugs, Surgery, artificial insemination, and all forms of in-vitro fertilization; Maternity Service, including related services and supplies, unless selected as an option (Complications of Pregnancy are covered as any other illness); Long Term Care; Inpatient Private Duty Nursing Service; Maintenance Care; Wigs (also referred to as cranial prothesis); and services and supplies rendered or provided for human organ or tissue transplants other than those specifically named in this policy.|
|READ YOUR POLICY CAREFULLY — This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!|