This is only a summar I f y ou want mor e detail about y our co erage and costs y ou can - PDF document

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan documentat www.bcbstx.com/coverage/Individual/index.html or by calling 1-888-697-0683. Why this Matters:AnswersImportant QuestionsYou must pay all the costs up to the deductible amount before this plan begins to pay for coveredservices you use. Check your policy or plan document to see when the deductible starts overNetwork $3,000 Individual/$9,000 FamilyOut-of-Network $6,000Individual/$18,000 FamilyDoesn't apply to certain servicesthat charge a copay, preventivecare, and prescription drugs.What is the overalldeductible ?(usually, but not always, January 1st). See the chart starting on page 2 for how much you payfor covered services after you meet the deductible .You must pay all the costs for these services up to the specific deductible amount before thisplan begins to pay for these services.Yes. Per Occurrence: Network$250/Out-of-Network $350Are there otherdeductibles for specificservices?Inpatient Admission. There are noother specific deductibles .The out-of-pocket limit is the most you could pay during a coverage period (usually one year)for your share of the cost of covered services. This limit helps you plan for health care expenses.Yes. For Network $6,350Individual/$12,700 FamilyFor Out-of-Network $12,700Individual/$25,400 FamilyIs there an out-of-pocket limit on my expenses?Even though you pay these expenses, they don't count toward the out-of-pocket limit .Premiums, balance-billed charges,and health care this plan does notcover.What is not included inthe out-of-pocket limit ?If you use an in-network doctor or other health care pr o vider , this plan will pay some or all ofthe costs of covered services. Be aware, your in-network doctor or hospital may use anYes. See www.bcbstx.com or call1-888-697-0683 for a list ofNetwork Providers.Does this plan use anetwor k of pr o viders ?out-of-network pr o vider for some services. Plans use the term in-network, pr eferr ed , orparticipating for pr o viders in their networ k . See the chart starting on page 2 for how thisplan pays different kinds of pr o viders .You can see the specialist you choose without permission from this plan.No. You don't need a referral tosee a specialist.Do I need a referral to seea specialist ?Some of the services this plan doesn't cover are listed on page 4. See your policy or plandocument for additional information about ex cluded ser vices .Yes.Are there services this plandoesn't cover? 1 of 7Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage/Individual/index.html.If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-697-0683 to request a copy.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Blue Choice Silver PPO 004Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: PPO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allo w ed amount for the service. For example, if the healthplan's allo w ed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven'tmet your deductible . The amount the plan pays for covered services is based on the allo w ed amount . If an out-of-network pr o vider charges more than the allo w ed amount , you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allo w ed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing. ) The plan may encourage you to use Network pr o viders by charging you lower deductibles , copayments , and coinsurance amounts. Limitations & ExceptionsYour Cost If You Usean Out-of-NetworkProviderYour Cost If You Usea Network ProviderServices You May NeedCommon Medical Event---none---40% coinsurance$35 copay/visitPrimary care visit to treat an injury or illnessIf you visit a health careprovider�s office orclinic40% coinsurance$55 copay/visitSpecialist visitAcupuncture not covered.40% coinsurance$35 copay/visitOther practitioner office visit---none---40% coinsuranceNo ChargePreventive care/screening/immunization---none---40% coinsurance20% coinsuranceDiagnostic test (x-ray, blood work)If you have a test40% coinsurance20% coinsuranceImaging (CT / PET scans, MRIs)One Copay per 30-Day Supply, up toa 90-Day Supply. Standard FormularyNo ChargeNo ChargePreferred Generic DrugsIf you need drugs totreat your illness orcondition50% coinsurance plusretail copay$10 retail/$20 mailcopay/ prescriptionNon-Preferred Generic Drugsapplies. certain women�s preventativeservices will be covered with no costto the member.More information aboutpr escription dr ug co v erage is available atwww.bcbstx.com/member/rx_drugs.html50% coinsurance plusretail copay$50 retail/$100 mailcopay/prescriptionPreferred Brand Drugs50% coinsurance plusretail copay$100 retail/$200 mailcopay/prescriptionNon-Preferred Brand DrugsStandard Formulary applies. certainwomen�s preventative services will becovered with no cost to the member.50% coinsurance pluscopay$150 copay/prescriptionSpecialty Drugs---none---40% coinsurance plus$300 copay/visit20% coinsurance plus$200 copay/visitFacility fee (e.g., ambulatory surgery center)If you have outpatientsurgery40% coinsurance20% coinsurancePhysician/surgeon fees 2 of 7Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage/Individual/index.html.If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-697-0683 to request a copy. Blue Choice Silver PPO 004Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: PPO Limitations & ExceptionsYour Cost If You Usean Out-of-NetworkProviderYour Cost If You Usea Network ProviderServices You May NeedCommon Medical EventCopay amount waived if admitted. Ifadmitted, Inpatient Hospital servicesdeductible will apply.20% coinsurance after$500 copay/visit20% coinsurance after$500 copay/visitEmergency room servicesIf you need immediatemedical attention---none---20% coinsurance20% coinsuranceEmergency medical transportationCopay may apply.40% coinsurance20% coinsuranceUrgent careNetwork $250/OON $350 InpatientPer Occurrence Deductible.40% coinsurance20% coinsuranceFacility fee (e.g., hospital room)If you have a hospitalstay---none---40% coinsurance20% coinsurancePhysician/surgeon feeNetwork $200/OON $300 OutpatientSurgery copay, facility only. Certainservices must be preauthorized.40% coinsurance$35 copay/visit or20% coinsurance forother outpatientservicesMental/Behavioral health outpatient servicesIf you have mentalhealth, behavioralhealth, or substanceabuse needsNetwork $250/OON $350 InpatientPer Occurrence Deductible. Allservices must be preauthorized.40% coinsurance20% coinsuranceMental/Behavioral health inpatient servicesNetwork $200/OON $300 OutpatientSurgery copay, facility only. Certainservices must be preauthorized.40% coinsurance$35 copay/visit or20% coinsurance forother outpatientservicesSubstance use disorder outpatient servicesNetwork $250/OON $350 InpatientPer Occurrence Deductible. Allservices must be preauthorized.40% coinsurance20% coinsuranceSubstance use disorder inpatient servicesCopay applies to first prenatal visit (perpregnancy)40% coinsurance$35 copay/initial visitPrenatal and postnatal careIf you are pregnantNetwork $250/OON $350 InpatientPer Occurrence Deductible.40% coinsurance20% coinsuranceDelivery and all inpatient services 3 of 7Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage/Individual/index.html.If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-697-0683 to request a copy. Blue Choice Silver PPO 004Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: PPO Limitations & ExceptionsYour Cost If You Usean Out-of-NetworkProviderYour Cost If You Usea Network ProviderServices You May NeedCommon Medical EventLimited to 60 visits per year.40% coinsurance20% coinsuranceHome health careIf you need helprecovering or have otherspecial health needsLimited to combined 35 visits per year,including Chiropractic.40% coinsurance20% coinsuranceRehabilitation services40% coinsurance20% coinsuranceHabilitation servicesLimited to 25 days per year.40% coinsurance20% coinsuranceSkilled nursing care---none---40% coinsurance20% coinsuranceDurable medical equipment40% coinsurance20% coinsuranceHospice serviceReimbursed up to $30Out-of-Network. One visit percalendar year. Up to age 19.CoveredNo ChargeEye examIf your child needsdental or eye careReimbursed up to $30 frames/$25single vision lenses Out-of-Network.CoveredNo ChargeGlassesOne pair per calendar year. Up to age19.---none---Not CoveredNot CoveredDental check-upExcluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other ex cluded ser vices .) Private-duty nursing (Only covered for extendedcare expenses)Dental Care (Adult)Acupuncture Bariatric surgeryLong-term care Weight loss programs Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Routine eye care (Adult)Infertility treatment (Diagnosis covered buttreatment and Invitro not covered)Chiropractic care Cosmetic surgery (Only for the correction ofcongenital deformities or for conditions resultingfrom accidental injuries, scars, tumors or diseases.When Medically Necessary.)Routine foot care (Only covered Networkconnection with diabetes, circulatory disorders ofthe lower extremities, peripheral vascular disease,peripheral neuropathy, or chronic arterial or venousinsufficiency) Non-emergency care when traveling outside theU.S. Hearing aids (Limited to 2 per 3 years) 4 of 7Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage/Individual/index.html.If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-697-0683 to request a copy. Blue Choice Silver PPO 004Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: PPO Your Rights to Continue Coverage:Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your pr emium . There are exceptions,however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage areaFor more information on your rights to continue coverage, contact the insurer at 1-888-697-0683. You may also contact your state insurance department athttp://www.tdi.texas.gov..Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a griev ance . For questions aboutyour rights, this notice, or assistance, you can contact: Texas Department of Insurance at (800) 578-4677 or visit http://www.tdi.texas.gov.Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as
minimum essential coverage. This plan or policy does provideminimum essential coverage.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-888-697-0683.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-697-0683.Chinese (m®): •àÁ Þm® 1 1-888-697-0683.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-697-0683. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 5 of 7Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage/Individual/index.html.If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-697-0683 to request a copy. Blue Choice Silver PPO 004Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: Individual/FamilyPlan Type: PPO About These CoverageExamples:Managing type 2 diabetes(routine maintenance ofa well-controlled condition)Having a baby(normal delivery) �$�P�R�X�Q�W�R�Z�H�G�W�R�S�U�R�Y�L�G�H�U�V��������$�P�R�X�Q�W�R�Z�H�G�W�R�S�U�R�Y�L�G�H�U�V�������These examples show how this plan might covermedical care in given situations. Use these �3�O�D�Q�S�D�\�V�������3�O�D�Q�S�D�\�V������ �3�D�W�L�H�Q�W�S�D�\�V�������3�D�W�L�H�Q�W�S�D�\�V������examples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.�6�D�P�S�O�H�F�D�U�H�F�R�V�W�V��6�D�P�S�O�H�F�D�U�H�F�R�V�W�V�$2,900Prescriptions$2,700Hospital charges (mother)$1,300Medical Equipment and Supplies$2,100Routine obstetric care This is not acostestimator. $700Office Visits and Procedures$900Hospital charges (baby)$300Education$900Anesthesia$100Laboratory tests$500Laboratory tests$100Vaccines, other preventive$200Prescriptions$5,400Total$200RadiologyDon�t use these examples toestimate your actual costs under$40Vaccines, other preventive$7,540Total�3�D�W�L�H�Q�W�S�D�\�V�the plan. The actual care youreceive will be different from these$3,000Deductibles$340Copays�3�D�W�L�H�Q�W�S�D�\�V�examples, and the cost of that carealso will be different.$3,060Deductibles$120Coinsurance$0Copays$80Limits or exclusionsSee the next page for importantinformation about these examples.$3,540Total$840Coinsurance$150Limits or exclusions$4,050Total 6 of 7Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage/Individual/index.html.If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-697-0683 to request a copy. Blue Choice Silver PPO 004Coverage Period: 01/01/2014-12/31/2014 Coverage Examples:Coverage for: Individual/FamilyPlan Type: PPO Questions and answers about Coverage Examples: �:�K�D�W�D�U�H�V�R�P�H�R�I�W�K�H�D�V�V�X�P�S�W�L�R�Q�V�E�H�K�L�Q�G�W�K�H�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�V�" Costs don�t include pr emiums . Sample care costs are based on nationalaverages supplied by the U.S. Department ofHealth and Human Services, and aren�tspecific to a particular geographic area orhealth plan. The patient�s condition was not an excludedor preexisting condition. All services and treatments started and endedin the same coverage period. There are no other medical expenses for anymember covered under this plan. Out-of-pocket expenses are based only ontreating the condition in the example. The patient received all care from in-networkpr o viders . If the patient had received carefrom out-of-network pr o viders , costs wouldhave been higher. �:�K�D�W�G�R�H�V�D�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�V�K�R�Z�"For each treatment situation, the CoverageExample helps you see how deductibles ,copayments , and coinsurance can add up. It alsohelps you see what expenses might be left up toyou to pay because the service or treatment isn�tcovered or payment is limited. �'�R�H�V�W�K�H�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�S�U�H�G�L�F�W�P�\�R�Z�Q�F�D�U�H�Q�H�H�G�V�" N o . Treatments shown are just examples. Thecare you would receive for this condition couldbe different based on your doctor�s advice,your age, how serious your condition is, andmany other factors. �'�R�H�V�W�K�H�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�S�U�H�G�L�F�W�P�\�I�X�W�X�U�H�H�[�S�H�Q�V�H�V�" N o . Coverage Examples are not costestimators. You can�t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Your owncosts will be different depending on the careyou receive, the prices your pr o viders charge,and the reimbursement your health planallows. �&�D�Q�,�X�V�H�&�R�Y�H�U�D�J�H�(�[�D�P�S�O�H�V�W�R�F�R�P�S�D�U�H�S�O�D�Q�V�" Y es . When you look at the Summary ofBenefits and Coverage for other plans, you�llfind the same Coverage Examples. When youcompare plans, check the
Patient Pays boxin each example. The smaller that number,the more coverage the plan provides. �$�U�H�W�K�H�U�H�R�W�K�H�U�F�R�V�W�V�,�V�K�R�X�O�G�F�R�Q�V�L�G�H�U�Z�K�H�Q�F�R�P�S�D�U�L�Q�J�S�O�D�Q�V�" Y es . An important cost is the pr emium youpay. Generally, the lower your pr emium , themore you�ll pay in out-of-pocket costs, suchas copayments , deductibles , and coinsurance .You should also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements (FSAs)or health reimbursement accounts (HRAs)that help you pay out-of-pocket expenses. 7 of 7Questions: Call 1-888-697-0683 or visit us at www.bcbstx.com/coverage/Individual/index.html.If you aren�t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-697-0683 to request a copy. Blue Choice Silver PPO 004Coverage Period: 01/01/2014-12/31/2014 Coverage Examples:Coverage for: Individual/FamilyPlan Type: PPO