March 17, 2010

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Blue Cross and Blue Shield of Texas – PPO Select Value Care - Plan I – TEXAS

A comparison of the PPO Select Value Care - Plan I 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 Value Care - Plan I Application PPO Select Value Care - Plan I Application
Brochure PPO Select Value Care - Plan I Brochure PPO Select Value Care - Plan I Brochure
Copay N/A N/A
Office Visit 50% of Allowable Amount 50% of Allowable Amount
Deductible N/A N/A
Coinsurance 50% 50%
Coinsurance Limit $10,000 Individual / $20,000 Family $20,000 Individual / $40,000 Family
Out-of-Pocket Maximum PPO Select Value Care - Plan I PPO Select Value Care - Plan I
Lifetime Maximum $5,000,000 $5,000,000
Prescription Drugs $200 deductible ($3,000 Calendar Year Maximum)
  • Generic: $10 copay for 30-day supply, $30 copay for 90-day supply
  • Preferred Brand: $30 copay for 30-day supply, $90 copay for 90-day supply
  • Non-Preferred Brand: $45 copay for 30-day supply, $135 copay for 90-day supply
    		•  $200 deductible ($3,000 Calendar Year Maximum)
  • Generic: $10 copay for 30-day supply, $30 copay for 90-day supply
  • Preferred Brand: $30 copay for 30-day supply, $90 copay for 90-day supply
  • Non-Preferred Brand: $45 copay for 30-day supply, $135 copay for 90-day supply
    		•
    Emergency Room 50% of Allowable Amount 50% of Allowable Amount
    Adult Preventative Care 50% of Allowable Amount. $300 Calendar Year maximum.
  • 50% of Allowable Amount. $300 Calendar Year maximum.
  • 100% of Allowable Amount for childhood immunizations (birth to age 8).
    		•
    Child Preventative Care
  • 50% of Allowable Amount. $300 Calendar Year maximum.
  • 100% of Allowable Amount for childhood immunizations (birth to age 8).
    		•
  • 50% of Allowable Amount. $300 Calendar Year maximum.
  • 100% of Allowable Amount for childhood immunizations (birth to age 8).
    		•
    Lab / X-Ray PPO Select Value Care - Plan I PPO Select Value Care - Plan I
    Maternity PPO Select Value Care - Plan I PPO Select Value Care - Plan I
    Physical Therapy PPO Select Value Care - Plan I PPO Select Value Care - Plan I
    Skilled Nursing 50% of Allowable Amount 50% of Allowable Amount
    Home Health Care 50% of Allowable Amount 50% of Allowable Amount
    Mental Health PPO Select Value Care - Plan I PPO Select Value Care - Plan I
    Hospital Care PPO Select Value Care - Plan I PPO Select Value Care - Plan I
    Optional Benefits PPO Select Value Care - Plan I PPO Select Value Care - Plan I