Your source for health insurance quotes and plans.

1-888-322-7557

Select Blue Advantage Plan II – Blue Cross and Blue Shield of Texas –

A comparison of the Select Blue Advantage Plan II 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 office visit copay includes same day lab and x-ray Physician office visits subject to deductible and coinsurance
Deductible
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
Out-of-Pocket Maximum
Lifetime Maximum No Limit No Limit
Prescription Drugs
    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
    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: 85% of Allowable Amount after $100 copayment amount (Waived if admitted to Hospital immediately following the visit) and Calendar Year Deductible; Physician Charges: 85% of Allowable Amount after Calendar Year Deductible Facility Charges: 85% of Allowable Amount after $100 copayment amount (Waived if admitted to Hospital immediately following the visit) and Calendar Year Deductible; Physician Charges: 85% of Allowable Amount after Calendar Year Deductible
Adult Preventative Care 100% of allowable amount no deductible 75% of Allowable Amount after Calendar Year Deductible
Child Preventative Care 100% of allowable amount no deductible 75% of Allowable Amount after Calendar Year Deductible; Childhood Immunization: 100% of Allowable Amount, No Deductible, from birth to age 8
Lab / X-Ray 85% of allowable amount after calendar year deductible 75% of Allowable Amount after Calendar Year Deductible
Maternity
Physical Therapy
Home Health Care 100% of Allowable Amount, No Calender Year Deductible 75% of Allowable Amount, No Deductible
Mental Health Not Covered Not Covered
Hospital Care 85% of Allowable Amount after Calendar Year Deductible 75% of Allowable Amount after Calendar Year Deductible
Verisign Truste