March 12, 2010

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Blue Cross and Blue Shield of Texas – Select Blue Advantage - Plan I – TEXAS

A comparison of the Select Blue Advantage - 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 Select Blue Advantage - Plan I Application Select Blue Advantage - Plan I Application
Brochure Select Blue Advantage - Plan I Brochure Select Blue Advantage - Plan I Brochure
Copay $25 None
Office Visit $25 office visit copay includes same day lab and x-ray, up to annual max of $750 Physician office visits subject to deductible and coinsurance
Deductible $250 Individual/$750 Family $500 Individual/$1,500 Family
Coinsurance 85% of the Allowable Amount for Eligible Expenses 75% 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 Select Blue Advantage - Plan I Select Blue Advantage - Plan I
Lifetime Maximum $5,000,000 $5,000,000
Prescription Drugs $3,000 Calendar Year maximum for each Participant. 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. 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 Facility Charges: 85% of Allowable Amount after $100* Copayment and Calendar Year Deductible (*Waived if admitted to Hospital immediately following the visit)
Physician Charges: 85% of Allowable Amount after Calendar Year Deductible		 Facility Charges: 85% of Allowable Amount after $100* Copayment and Calendar Year Deductible (*Waived if admitted to Hospital immediately following the visit)
Physician Charges: 85% of Allowable Amount after Calendar Year Deductible
Adult Preventative Care
  • 100% of Allowable Amount subject to Physician office visit Copayment. $300 Calendar Year maximum.
    		•
  • 75% of Allowable Amount after Calendar Year Deductible.
    		•
    Child Preventative Care
  • 100% of Allowable Amount after Physician office visit Copay Amount. $300 Calendar Year maximum.
  • Childhood Immunization: 100% of Allowable Amount, No Deductible, from birth to age 8.
    		•
  • 75% of Allowable Amount after Calendar Year Deductible.
    		•
    Lab / X-Ray 85% of allowable amount after calendar year deductible 75% of Allowable Amount after Calendar Year Deductible
    Maternity Select Blue Advantage - Plan I Select Blue Advantage - Plan I
    Physical Therapy Select Blue Advantage - Plan I Select Blue Advantage - Plan I
    Skilled Nursing
  • 100% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
    		•
  • 75% 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
    		•
  • 75% of Allowable Amount, No Deductible
  • Limited to $5,000 each Calendar Year
    		•
    Mental Health Not Covered Not Covered
    Hospital Care 85% of Allowable Amount after Calendar Year Deductible 75% of Allowable Amount after Calendar Year Deductible
    Optional Benefits Select Blue Advantage - Plan I Select Blue Advantage - Plan I