Blue Cross and Blue Shield of Texas PPO Select Value Care Plan I II III Plan Information
Coverage Level 50%
Physician/Hospital Network BlueChoice or BlueCard Preferred Provider Organization
Lifetime Benefit $5 Million
Individual Out-of-Pocket Expense $10,000-Plan I; $20,000-Plan II; $30,000-Plan III
Office Visit Co-pay Coinsurance
Family Out-of-Pocket Expense $20,000-Plan I; $40,000-Plan II; $60,000-Plan III
Outpatient Physician Medical Services Coinsurance
Outpatient Physician Surgical Services Coinsurance
Preventative Care Coinsurance; $300 max per year
Childhood Immunizations 100% to 8 years of age
Inpatient Physician Medical/Surgical Services Coinsurance
Outpatient Hospital Services Coinsurance
Outpatient Hospital Diagnostic Testing Coinsurance
Inpatient Hospital Services and Diagnostic Testing Coinsurance
Outpatient Prescription Drugs $200 deductible and $10 copay/generic; $30 copay/preferred; $45 copay/non-preferred; $3,000 calendar year max
Other Blue Cross and Blue Shield of Texas health insurance plans:
