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PPO Select Choice Plan VII – Blue Cross and Blue Shield of Texas –

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

  Network Non-Network
Copay $25 None
OfficeVisit $25 copayment applies to office visit/consultation only Physician office visits subject to deductible and coinsurance
Deductible
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
Out-of-Pocket Maximum
Lifetime Maximum No Limit No Limit
Prescription Drugs
    Pharmacy deductible: $200
    Retail Pharmacy
  • 30-Day Supply on each occasion dispensed: Generic - $10; Preferred Brand Name - $30; Non-Preferred Brand Name - $45
  • 90-Day Supply: Generic - $30; Preferred Brand Name - $90; Non-Preferred Brand Name - $135
    Mail Service
  • 90-Day Supply: Generic - $20; Preferred Brand Name - $60; Non-Preferred Brand Name - $90
    Pharmacy deductible: $200
    Retail Pharmacy
  • 30-Day Supply on each occasion dispensed: Generic - $10; Preferred Brand Name - $30; Non-Preferred Brand Name - $45
  • 90-Day Supply: Generic - $30; Preferred Brand Name - $90; Non-Preferred Brand Name - $135
    Mail Service
  • 90-Day Supply: Generic - $20; Preferred Brand Name - $60; Non-Preferred Brand Name - $90
Emergency Room Facility Charges: 80% of Allowable Amount Calender year deductible; Physician Charges: 80% of Allowable Amount after Calendar Year Deductible Facility Charges: 80% of Allowable Amount Calender year deductible; Physician Charges: 80% of Allowable Amount after Calendar Year Deductible
Adult Preventative Care 100% of allowable amount no deductible 70% of allowable amount after calendar year deductible
Child Preventative Care 100% of allowable amount no deductible 70% of Allowable Amount after; Calendar Year Deductible; Childhood Immunization: 100% of Allowable Amount, No Deductible, from birth to age 8
Lab / X-Ray 80% of Allowable Amount after Calendar Year Deductible 70% of Allowable Amount after Calendar Year Deductible
Maternity
Physical Therapy
Home Health Care 100% of Allowable Amount, No Deductible 70% of Allowable Amount, No Deductible
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
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