Blue Cross Blue Shield of Texas
PPO Select Saver - Plan I Health Insurance Plan
A plan summary of the Blue Cross Blue Shield of Texas PPO Select Saver - Plan I is detailed out below for both In Network and Out of Network coverage.
| In Network |
Out of Network |
Copay |
25% after deductible |
40% after deductible |
Office Visits |
25% |
40% |
| Annual Deductible |
Individual:$500 Family:$1,500
|
Individual:$1,000 Family:$3,000
|
| Annual Out-Of-Pocket Limit |
Individual:$3,000 Family:$9,000 (Deductible not Included)
|
Individual:$6,000 Family:$18,000 (Deductible not Included)
|
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Generic:$10 Preferred Brand:$40 Non-Preferred Brand:$55 ($200 Deductible)
|
Generic:$10 Preferred Brand:$40 Non-Preferred Brand:$55 ($200 Deductible)
|
| Laboratory & X-Ray |
25% |
40% |
| Annual Physical Exam |
No Charge |
40% |
| Annual OB-GYN Exam |
No Charge |
40% |
Well Baby Care |
No Charge |
40% |
| Outpatient Surgery |
25%
|
40% |
| Emergency Room |
25% |
25% |
| Inpatient Hospital |
25% |
40% |
| Ambulance |
25% |
25% |
| Home Health Care |
No Charge |
30% |
| Mental Health - Outpatient |
Not Covered |
Not Covered |
| Chiropractic Care |
See Brochure |
See Brochure |
Acupuncture |
Not Covered |
Not Covered |
| Mental Health - Inpatient |
Not Covered
|
Not Covered |
| Chemical Dependency |
Not Covered |
Not Covered |
| Maternity Care |
Not Covered |
Not Covered |
To learn more about your
individual and family
Texas health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.
NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the standard health plan's underwriting guidelines.
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