March 20, 2010

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Blue Cross and Blue Shield of Texas – PPO Select Choice - Plan V – TEXAS

A comparison of the PPO Select Choice - Plan V offered by Blue Cross and Blue Shield of Texas is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application PPO Select Choice - Plan V Application PPO Select Choice - Plan V Application
Brochure PPO Select Choice - Plan V Brochure PPO Select Choice - Plan V Brochure
Copay $25 None
Office Visit $25 copayment applies to office visit/consultation only Physician office visits subject to deductible and coinsurance
Deductible $2,500 Individual/$7,500 Family $5,000 Individual/$15,000 Family
Coinsurance 80% of the Allowable Amount for Eligible Expenses 70% of the Allowable Amount for Eligible Expenses
Coinsurance Limit $3,000 Individual/$6,000 Family $6,000 Individual/$12,000 Family
Out-of-Pocket Maximum PPO Select Choice - Plan V PPO Select Choice - Plan V
Lifetime Maximum $5,000,000 $5,000,000
Prescription Drugs $3,000 Calendar Year maximum for each Participant. $200 deductible. Copayment is $10 for Generic Drug, $30 for Preferred Brand Name Drug, $45 for Non-Preferred Brand Name Drug. Copayment is based on 30-day supply on each occasion dispensed. 90-day supply requires three separate Copayment Amounts. $3,000 Calendar Year maximum for each Participant. $200 deductible. Copayment is $10 for Generic Drug, $30 for Preferred Brand Name Drug, $45 for Non-Preferred Brand Name Drug. Copayment is based on 30-day supply on each occasion dispensed. 90-day supply requires three separate Copayment Amounts.
Emergency Room 80% of Allowable Amount after Calendar Year Deductible 80% of Allowable Amount after Calendar Year Deductible
Adult Preventative Care
  • 100% of allowable amount after physician office visit copayment amount
  • $300 combined Calendar Year maximum for in and out of network
    		•
  • 70% of Allowable Amount afterCalendar Year Deductible.
  • Childhood Immunization: 100% of Allowable Amount, No Deductible, from birth to age 8
  • $300 combined Calendar Year maximum for in and out of network
    		•
    Child Preventative Care
  • 100% of Allowable Amount after Physician office visit Copay Amount
  • Childhood Immunization: 100% of Allowable Amount, No Deductible, from birth to age 8
  • $300 combined Calendar Year maximum for in and out of network
    		•
  • 70% of Allowable Amount afterCalendar Year Deductible.
  • Childhood Immunization: 100% of Allowable Amount, No Deductible, from birth to age 8
  • $300 combined Calendar Year maximum for in and out of network
    		•
    Lab / X-Ray 80% of Allowable Amount after Calendar Year Deductible 70% of Allowable Amount after Calendar Year Deductible
    Maternity PPO Select Choice - Plan V PPO Select Choice - Plan V
    Physical Therapy PPO Select Choice - Plan V PPO Select Choice - Plan V
    Skilled Nursing
  • 100% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
    		•
  • 70% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
    		•
    Home Health Care
  • 100% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
    		•
  • 70% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
    		•
    Mental Health Not Covered Not Covered
    Hospital Care 80% of Allowable Amount after the Calendar Year Deductible 70% of Allowable Amount after the Calendar Year Deductible
    Optional Benefits PPO Select Choice - Plan V PPO Select Choice - Plan V