Blue Cross Blue Shield of Texas
PPO Select Blue Advantage - Plan I Health Insurance Plan
A plan summary of the Blue Cross Blue Shield of Texas PPO Select Blue Advantage - Plan I is detailed out below for both In Network and Out of Network coverage.
| In Network |
Out of Network |
Copay |
15% after deductible |
25% after deductible |
Office Visits |
$25
(Includes same day lab and x-ray during office visit)
|
25% |
| Annual Deductible |
Individual:$250 Family:$750
|
Individual:$500 Family:$1,500
|
| Annual Out-Of-Pocket Limit |
Individual:$3,000 Family:$6,000 (Deductible not Included)
|
Individual:$6,000 Family:$12,000 (Deductible not Included)
|
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Generic:$10 Preferred Brand:$30 Non-Preferred Brand:$45
|
Generic:$10 Preferred Brand:$30 Non-Preferred Brand:$45 |
| Laboratory & X-Ray |
15% |
25% |
| Annual Physical Exam |
No Charge |
25% |
| Annual OB-GYN Exam |
No Charge |
25% |
Well Baby Care |
No Charge |
25% |
| Outpatient Surgery |
15%
|
25% |
| Emergency Room |
$100 (Waived if Admitted) after 15% |
$100 (Waived if Admitted) after 15% |
| Inpatient Hospital |
15% |
25% |
| Ambulance |
15% |
15% |
| Home Health Care |
No Charge |
25% |
| 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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