Medical Insurance
ABOUT MEDICAL
Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis.
For full plan details, please visit your benefit website: www.txescbenefits.com
BCBSTX EMPLOYEE
BCBS STANDARD PPO Employee Only $525.00 Employee & Spouse $1,089.00 Employee & Child(ren) $869.00 Employee & Family $1,432.00 BCBS HMO Employee Only $401.00 Employee & Spouse $831.00 Employee & Child(ren) $662.00 Employee & Family $1,092.00 HD PPO Employee Only $427.00 Employee & Spouse $886.00 Employee & Child(ren) $706.00 Employee & Family $1,165.00 HD HMO Employee Only $290.00 Employee & Spouse $602.00 Employee & Child(ren) $480.00 Employee & Family $791.00 12
BENEFITS
Coverage Period: 07/01/2023 –06/30/2024 : MTBCB026 Blue Choice PPO SM Basic 026
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.
NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.
Why This Matters:
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/ .
You don’t have to meet deductibles for specific services.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work).
Check with your provider before you get services.
You can see the specialist you choose without a referral.
Answers
Important Questions
Network: $3,000 Individual/$9,000 Family Out-of-Network: $6,000
Individual/$18,000 Family
Yes. Network office visits with a copayment, prescription drugs and preventive care services and services with a copayment are covered before you meet your deductible.
No.
Network: $7,350 Individual/$14,700 Family Out-of-Network: Unlimite d
Individual/Unlimited Family
Premiums, balance-billing charges, and health care this plan doesn't cover.
Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network provide rs.
No.
What is the overall deductible?
Are there services covered before you meet your deductible?
Are there other deductibles for specific services?
What is the out-of-pocket limit for this plan?
What is not included in the out-of-pocket limit?
Will you pay less if you use a network provider?
Do you need a referral to see a specialist?
Coverage for: Individual/Family | Plan Type: PPO 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
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What You Will Pay
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
Inpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.
Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional charge will not apply to any deductible or out-of-pocket amounts. Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rx- drugs/drug-lists/drug-lists
*For more information about limitations and exceptions, see the plan or policy document at
. Page 2 of 8
www.bcbstx.com/member/policy-forms/2023
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event Services You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Primary care visit to treat an injury o r illness $50/visit; deductible does not apply 50% coinsurance Virtual visits are available. See your benefit booklet* for details. Specialist visit $100/visit; deductible does not apply 50% coinsurance None
or
Preventive care/screening/ immunization No Charge; deductible
50% coinsurance
If you visit a health care provider’s office
clinic
does not apply
Diagnostic
(x-ray,
30% coinsurance 50% coinsurance
test
blood work)
30% coinsurance 50% coinsurance
If you have a test Imaging (CT/PET scans, MRIs)
RetailPreferredNo Charge Non-Preferred - $10/prescription MailNo Charge; deductible does not
Retail$10/prescription; deductible does
plus
Preferred generic drugs
apply
not apply
50% additional charge
RetailPreferred
$10/prescription Non-Preferred
$20/prescription Mail
$30/prescription; deductible
Retail
Non-preferred generic drugs
-
-
-
does not apply
$20/prescription; deductible does not apply plus 50% additional charge
14
$250/prescription; deductible does not apply plus 50% additional charge day supply, regardless of the amount or type of insulin needed to fill the prescription.
Preferred$50/prescription
$150/prescription; deductible does not apply plus 50% additional charge Non-preferred specialty drugs
plus 30%
$150/prescription;
deductible does not apply
Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Preferred brand drugs surgery Physician/surgeon fees 30% coinsurance 50% coinsurance
If you have outpatient
Emergency
*For more information about limitations and exceptions, see the plan or policy document at
. Page 3 of 8
www.bcbstx.com/member/policy-forms/2023
Out-of-Network
Retail
Non-Preferred
Retail
Retail
Non-Preferred
Retail
Facility fee (e.g., ambulatory
What You Will Pay 30% coinsurance
Common Medical Event Services You May Need Network Provider (You will pay the least) 50% coinsurance
- $70/prescription Mail$150/prescription; deductible does not apply
$70/prescription; deductible does not apply plus 50% additional charge Non-preferred brand drugs
Preferred$100/prescription
- $120/prescription Mail$300/prescription; deductible does not apply
-
$120/prescription;
deductible does not apply plus 50% additional charge Preferred specialty drugs
deductible does not apply
$250/prescription;
surgery center)
care $500/visit
coinsurance $500/visit
coinsurance Copayment waived
Emergency medical transportation 30% coinsurance 30% coinsurance
immediate medical attention Urgent care $75/visit; deductible does not apply 50% coinsurance None Facility fee (e.g., hospital room) 30% coinsurance 50% coinsurance
hospital stay Physician/surgeon fees30% coinsurance 50% coinsurance Preauthorization
Preauthorization
15
Certain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.
room
plus 30%
if admitted.
If you need
If you have a
required.
penalty: $250 out-of-network. See your benefit booklet* for details.
What You Will Pay
Certain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.
Preauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.
Copayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to preventive services. Depending on the type of services, copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).
60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.
For Outpatient, limited to combined 35 visits per year, including Chiropractic.
25-day maximum per calendar year. Preauthorization may be required for out-ofnetwork. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details.
None
Inpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.
No Charge; deductible does not apply
May
If you need mental health, behavioral health, or substance abuse services
If you are pregnant
If you need help recovering or have other special health needs
*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023 .
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Common Medical Event Services You
Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Outpatient services
50% coinsurance
$50/office visit; deductible does not apply or 30% coinsurance for other outpatient services
Inpatient services 30% coinsurance 50% coinsurance
Office
Primary
50% coinsurance Childbirth/delivery professional services 30% coinsurance 50% coinsurance
visits
Care: $50/initial visit Specialist: $100/initial visit; deductible does not apply
Childbirth/delivery facility services 30% coinsurance 50% coinsurance
Home health care 30% coinsurance 50% coinsurance
Rehabilitation services 30% coinsurance 50% coinsurance Habilitation services 30% coinsurance 50% coinsurance
Skilled nursing care 30% coinsurance 50% coinsurance
Durable medical equipment 30% coinsurance 50% coinsurance
Hospice services
50% coinsurance
16
What You Will Pay
information
and
the plan or policy document at www.bcbstx.com/member/policy-forms/2023 . Page 5 of 8
Common Medical Event Services You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Outpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details. Children’s eye exam Not Covered Not Covered None Children’s glasses Not Covered Not Covered If your child needs dental or eye care Children’s dental check-up Not Covered Not Covered None 17
*For more
about limitations
exceptions, see
Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Excluded Services & Other Covered Services : Services Your Plan
Private-duty nursing
Routine eye care (Child)
Weight loss programs
Dental care (Adult and Child)
Long-term care
Non-emergency care when traveling outside the U.S.
Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed)
Acupuncture
Bariatric surgery
Cosmetic surgery
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)
Infertility treatment (Invitro and artificial insem ination are not covered unless shown in your plan document)
Routine eye care (Adult)
Chiropractic care (OutpatientMax.35 visits/year combined with habilitation and rehabilitation services)
Hearing aids (Limited to one hearing aid per ear every 36 months)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com
. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323
x61565 or www.cciio.cms.gov . Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html .
Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
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18
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.
Chinese ( 中文 ): 如果需要中文的帮助， 请拨 打 这 个号 码 1-800-521-2227.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 7 of 8
19
shown are just examples of how this plan might cover medical care. Your actual costs will be different
on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
be responsible for the other costs
Page 8 of 8
This
Treatments
(deductibles, copayments
coinsurance)
pay under
plans. Please
examples
coverage. The plan’s overall deductible $3,000 Specialist copayment $100 Hospital (facility) coinsurance30% Other coinsurance 30% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $3,000 Copayments $50 Coinsurance $2,900 What isn’t covered Limits or exclusions $60 The total Peg would pay is $6,010 The plan’s overall deductible $3,000 Specialist copayment $100 Hospital (facility) coinsurance30% Other coinsurance 30% This EXAMPLE event includes services like: Primary care physician office visits (including
Diagnostic tests (blood
Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $900 Copayments $900 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $1,820 The plan’s overall deductible $3,000 Specialist copayment $100 Hospital (facility) coinsurance30% Other coinsurance 30% This EXAMPLE event includes services like: Emergency room
(including
Diagnostic test ( x-ray ) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $2,100 Copayments $600 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,700
EXAMPLE covered services. Peg is Having a Baby (9
Managing Joe’s Type 2 Diabetes (a year of routine in-network
of
Mia’s Simple Fracture (in-network emergency room visit and follow up care) 20
About these Coverage Examples:
is not a cost estimator.
depending
amounts
and
and excluded services under the plan. Use this information to compare the portion of costs you might
different health
note these coverage
are based on self-only
disease education)
work)
care
medical supplies)
The plan would
of these
months of in-network pre-natal care and a hospital delivery)
care
a wellcontrolled condition)
bcbstx.com 21
bcbstx.com 22
0 4202/13/8 C :rof egarevo
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
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| P
Coverage Period: 01/01/2023 –12/31/2023 : MTBAB026 Blue Advantage 026 SM
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The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.
NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-877-299-2377. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/ .
This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. 03202/10/9
Why This Matters:
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
Yes. C :doireP egarevo
Answers
Important Questions
$3,000 Individual/$9,000 Family
Yes. Network office visits, prescription drugs and preventive care services are covered before you meet your deductible.
Yes. ER $500. There are no other specific deductibles.
$7,350 Individual/$14,700 Family
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
What is the overall deductible?
Are there services covered before you meet your deductible?
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Premiums, balance-billing charges, and health care this plan doesn't cover.
Yes. See www.bcbstx.com/go/bahmo or call 1-877-299-2377 for a list of Participating Providers.
Are there other deductibles for specific services?
What is the out-of-pocket limit for this plan?
What is not included in the out-of-pocket limit?
Coverage for: Individual/Family | Plan Type: HMO 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
H 23
Will you pay less if you use a network provider?
Page 1 of 7
Do you need a referral to see a specialist?
between
exceptions, see
*For more
information
www.bcbstx.com/member/policy-forms/2023 Page 2 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Primary care visit to treat an injury o r illness $50/visit; deductible does not apply Not Covered Virtual visits are available. See your benefit booklet* for details. Specialist visit $100/visit; deductible does not apply Not Covered Referral required If you visit a health care provider’s office or clinic Preventive care/screening/ immunization No Charge; deductible does not apply Not Covered You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood work) 30% coinsurance Not Covered If you have a test Imaging (CT/PET scans, MRIs) 30% coinsurance Not Covered None Preferred generic drugs RetailPreferredNo Charge Non-Preferred - $10/prescription MailNo Charge; deductible does not apply Not Covered Non-preferred generic drugs RetailPreferred$10/prescription Non-Preferred - $20/prescription Mail - $30/prescription;deductible does not apply Not Covered If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rx- drugs/drug-lists/drug-lists Preferred brand drugs RetailPreferred$50/prescription Non-Preferred - $70/prescription Mail$150/prescription; deductible does not apply Not Covered
drug is available.
drug list
30-
24
about limitations and
the plan or policy document at
Limited to a 30-day supply at retail (or a 90day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference
the cost of a brand name drug and a generic may also be required if a generic
Cost Sharing for insulin included in the
will not exceed $25 per prescription for a
day supply, regardless of the amount or type of insulin needed to fill the prescription.
What You Will Pay
applies to first prenatal visit (per pregnancy). Cost sharing does not apply to certain preventive
Depending on the type of services, coinsurance may apply.
*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023
Page 3 of 7
Common Medical Event Services You May Need Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Non-preferred brand drugs RetailPreferred$100/prescription Non-Preferred - $120/prescription Mail - $300/prescription;deductible does not apply Not Covered Preferred specialty drugs $150/prescription; deductible does not apply Not Covered Non-preferred specialty drugs $250/prescription; deductible does not apply Not Covered Facility fee (e.g., ambulatory surgery center) 30% coinsurance Not Covered If you have outpatient surgery Physician/surgeon fees 30% coinsurance Not Covered For Outpatient Infusion Therapy, see your benefit booklet* for details. Emergency room care $500/visit plus 30% coinsurance $500/visit plus 30% coinsurance Per Occurrence Deductible waived if admitted. Emergency medical transportation 30% coinsurance 30% coinsurance If you need immediate medical attention Urgent care $75/visit; deductible does not apply Not Covered None Facility fee (e.g., hospital room) 30% coinsurance Not Covered If you have a hospital stay Physician/surgeon fees30% coinsurance Not Covered None Outpatient services $50/office visit; deductible does not apply or 30% coinsurance for other outpatient services Not Covered None If you need mental health, behavioral health, or substance abuse services Inpatient services 30% coinsurance Not Covered None If you are pregnant Office visits Primary Care: $50/initial visit Specialist: $100/initial visit; deductible does not apply Not Covered Copayment
25
services.
What You Will Pay
*For more information about limitations and exceptions, see the
plan
policy document at www.bcbstx.com/member/policy-forms/2023 Page 4 of 7
Common Medical Event Services You May Need Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Childbirth/delivery professional services 30% coinsurance Not Covered Childbirth/delivery facility services 30% coinsurance Not Covered Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Home health care 30% coinsurance Not Covered None Rehabilitation services 30% coinsurance Not Covered Habilitation services 30% coinsurance Not Covered None Skilled nursing care 30% coinsurance Not Covered 60 day maximum per calendar year. Durable medical equipment 30% coinsurance Not Covered None If you need help recovering or have other special health needs Hospice services 30% coinsurance Not Covered None Children’s eye exam Primary Care: $50 Specialist: $100; deductible does not apply Not Covered Eye screenings only. Does not include refractions. One visit per year for members ages 17 and younger. Children’s glasses Not Covered Not Covered If your child needs dental or eye care Children’s dental check-up Not Covered Not Covered None 26
or
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Long-term care
Non-emergency care when traveling outside the U.S.
Weight loss programs
Children's glasses Cosmetic surgery
Dental care (Adult)
Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed)
Acupuncture
Bariatric surgery
Children's dental check-up
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Routine eye care (AdultOne visit every two years for members ages 18 and older)
Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)
Infertility treatment (Invitro not covered)
Chiropractic care (Preauthorization required)
Private-duty nursing (Only when ordered or authorized by the Primary Care Physician)
Hearing aids (Limited to one hearing aid per ear every 36 months)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com . For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform . For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov . Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html .
Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Page 5 of 7
27
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-877-299-2377.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.
Chinese ( 中文 ) : 如果需要中文的帮助， 请拨 打 这 个号 码 1-877-299-2377 .
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 6 of 7
28
About
shown are just examples of how this plan might cover medical care. Your actual costs will be different
on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
be responsible for the other costs
Page 7 of 7
This
Treatments
(deductibles, copayments
coinsurance)
pay under
plans. Please
examples
coverage. The plan’s overall deductible $3,000 Specialist copayment $100 Hospital (facility) coinsurance30% Other coinsurance 30% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $3,000 Copayments $50 Coinsurance $2,900 What isn’t covered Limits or exclusions $60 The total Peg would pay is $6,010 The plan’s overall deductible $3,000 Specialist copayment $100 Hospital (facility) coinsurance30% Other coinsurance 30% This EXAMPLE event includes services like: Primary care physician office visits (including
Diagnostic tests (blood
Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $900 Copayments $900 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $1,820 The plan’s overall deductible $3,000 Specialist copayment $100 Hospital (facility) coinsurance30% Other coinsurance 30% This EXAMPLE event includes services like: Emergency room
(including
Diagnostic test ( x-ray ) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $2,100 Copayments $600 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,700
EXAMPLE covered services. Peg is Having a Baby (9
Managing Joe’s Type 2 Diabetes (a year of routine in-network
of
Mia’s Simple Fracture (in-network emergency room visit and follow up care) 29
these Coverage Examples:
is not a cost estimator.
depending
amounts
and
and excluded services under the plan. Use this information to compare the portion of costs you might
different health
note these coverage
are based on self-only
disease education)
work)
care
medical supplies)
The plan would
of these
months of in-network pre-natal care and a hospital delivery)
care
a wellcontrolled condition)
bcbstx.com 30
bcbstx.com 31
Coverage Period: 07/01/2023 –06/30/2024 : MTBCP007H Blue Choice PPO SM HSA 007H
:epyT nal
0 4202/13/8 C :rof egarevo
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
| P
I ylimaF + laudividn
P 32
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.
NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-800-521-2227. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/ .
Why This Matters:
You don’t have to meet deductibles for specific services.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
You can see the specialist you choose without a referral. 03202/10/9
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
No. C :doireP egarevo
Answers
Important Questions
Network: $5,000 Individual/$10,000 Family
Out-of-Network: $10,000
Individual/$20,000 Family
Yes. In-Network preventive care services are covered before you meet you r deductible.
No.
Network: $5,000
Individual/$10,000 Family
Out-of-Network: Unlimite d
Individual/Unlimited Family
Premiums, balance-billing charges, and health care this plan doesn't cover.
Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network provide rs.
What is the overall deductible?
Are there services covered before you meet your deductible?
Are there other deductibles for specific services?
What is the out-of-pocket limit for this plan?
What is not included in the out-of-pocket limit?
Will you pay less if you use a network provider?
Coverage for: Individual/Family | Plan Type: PPO 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
Page 1 of 7
Do you need a referral to see a specialist?
What You Will Pay
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what
require Preauthorization for
$250
Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.
*For more information about limitations and exceptions, see the plan or policy document at
. Page 2 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met,
a deductible applies.
Common Medical Event Services You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Primary care visit to treat an injury o r illness No Charge after deductible 30% coinsurance Virtual visits are available. See your benefit booklet* for details. Specialist visit No Charge after deductible 30% coinsurance None If you visit a health care provider’s office or clinic Preventive care/screening/ immunization No Charge; deductible does not apply 30% coinsurance
Diagnostic test (x-ray, blood work) No Charge after deductible 30% coinsurance If you have a test Imaging (CT/PET scans, MRIs) No Charge after deductible 30% coinsurance Inpatient:
Outpatient:
Preferred generic drugs No Charge after deductible RetailNo Charge after deductible plus 50% additional charge Non-preferred generic drugs No Charge after deductible RetailNo Charge after deductible plus 50% additional charge Preferred brand drugs No Charge after deductible RetailNo Charge after deductible plus 50% additional charge Non-preferred brand drugs No Charge after deductible RetailNo Charge after deductible plus 50% additional charge Preferred specialty drugs No Charge after deductible No Charge after deductible plus 50% additional charge If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rx- drugs/drug-lists/drug-lists Non-preferred specialty drugs No Charge after deductible No Charge after deductible plus 50% additional charge Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional charge will not apply to any deductible or out-of-pocket amounts.
sharing
insulin
in the drug list will not
per prescription for a 30day supply,
of the
or
of
to
the prescription. 33
www.bcbstx.com/member/policy-forms/2023
if
your plan will pay for.
Certain services may
out-of-network; failure to preauthorize may result in
reduction in benefits.
Cost
for
included
exceed $25
regardless
amount
type
insulin needed
fill
What You Will Pay
Certain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.
penalty: $250 out-of-network. See your benefit booklet* for details.
Certain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.
*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023 .
Page 3 of 7
Common Medical Event Services You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Facility fee (e.g., ambulatory surgery center) No Charge after deductible 30% coinsurance If you have outpatient surgery Physician/surgeon fees No Charge after deductible 30% coinsurance
Emergency room care No Charge after deductible No Charge after deductible None Emergency medical transportation No Charge after deductible No Charge after deductible If you need immediate medical attention Urgent care No Charge after deductible 30% coinsurance None Facility fee (e.g., hospital room) No Charge after deductible 30% coinsurance If you have a hospital stay Physician/surgeon fees No Charge after deductible 30% coinsurance Preauthorization
Preauthorization
Outpatient services No Charge after deductible 30% coinsurance
If you need mental health, behavioral health, or substance abuse services Inpatient services No Charge after deductible 30% coinsurance Preauthorization required out-of-network;
to admission will
in $250 reduction in benefits. Office visits No Charge after deductible 30% coinsurance Childbirth/delivery professional services No Charge after deductible 30% coinsurance If you are pregnant Childbirth/delivery facility services No Charge after deductible 30% coinsurance If you need help recovering or have other special health Home health care No Charge after deductible 30% coinsurance 60 visits/year. Preauthorization
be
out-of-network. Failure to preauthorize may
in 50% reduction
34
required.
failure to preauthorize at least two business days prior
result
may
required for
result
in
Preauthorization may be required for
Preauthorization may be required for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.
What You Will Pay
*For more information about limitations and exceptions, see the plan or policy document
www.bcbstx.com/member/policy-forms/2023 . Page 4 of 7
at
Common Medical Event Services You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information benefits not to exceed $500. See your benefit booklet* for details. Rehabilitation services No Charge after deductible 30% coinsurance Habilitation services No Charge after deductible 30% coinsurance For Outpatient, limited to combined 35 visits per year, including Chiropractic. Skilled nursing care No Charge after deductible 30% coinsurance 25-day maximum per calendar year. Preauthorization may be required for out-ofnetwork. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details. Durable medical equipment No Charge after deductible 30% coinsurance None needs Hospice services No Charge after deductible 30% coinsurance Inpatient:
out-of-network;
Outpatient:
Children’s eye exam Not Covered Not Covered None Children’s glasses Not Covered Not Covered If your child needs dental or eye care Children’s dental check-up Not Covered Not Covered None 35
failure to preauthorize may result in a $250 reduction in benefits.
Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Excluded Services & Other Covered Services : Services Your Plan
Private-duty nursing
Routine eye care (Child)
Weight loss programs
Dental care (Adult and Child)
Long-term care
Non-emergency care when traveling outside the U.S.
Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed)
Acupuncture
Bariatric surgery
Cosmetic surgery
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)
Infertility treatment (Invitro and artificial insem ination are not covered unless shown in your plan document)
Routine eye care (Adult)
Chiropractic care (OutpatientMax.35 visits/year combined with habilitation and rehabilitation services)
Hearing aids (Limited to one hearing aid per ear every 36 months)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com
. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323
x61565 or www.cciio.cms.gov . Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html .
Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Page 5 of 7
36
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.
Chinese ( 中文 ): 如果需要中文的帮助， 请拨 打 这 个号 码 1-800-521-2227.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 6 of 7
37
shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
Page 7 of 7
This
Treatments
(deductibles, copayments
coinsurance)
pay under
examples
coverage. The plan’s overall deductible $5,000 Specialist $0 Hospital (facility) $0 Other $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $5,000 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,060 The plan’s overall deductible $5,000 Specialist $0 Hospital (facility) $0 Other $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $2,300 Copayments $300 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $2,620 The plan’s overall deductible $5,000 Specialist $0 Hospital (facility) $0 Other $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test ( x-ray ) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $2,800 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,800 The plan
EXAMPLE covered services.
(9
of
Managing Joe’s Type 2 Diabetes (a year of routine in-network
of
controlled condition) Mia’s Simple Fracture (in-network emergency room visit and
care) 38
About these Coverage Examples:
is not a cost estimator.
amounts
and
and excluded services under the plan. Use this information to compare the portion of costs you might
different health plans. Please note these coverage
are based on self-only
would be responsible for the other costs of these
Peg is Having a Baby
months
in-network pre-natal care and a hospital delivery)
care
a well-
follow up
bcbstx.com 39
bcbstx.com 40
0 4202/13/8 C :rof egarevo
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
:epyT nal
| P
Coverage Period: 01/01/2023 –12/31/2023 : MTBAB014H Blue Advantage HSA 014H SM
I ylimaF + laudividn
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services.
NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-877-299-2377. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/ .
This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. 03202/10/9
Why This Matters:
$5,000 Individual/$10,000 Family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
Yes. C :doireP egarevo
Answers
Important Questions
What is the overall deductible?
Yes. In-Network preventive care services are covered before you meet you r deductible.
Are there services covered before you meet your deductible?
You don’t have to meet deductibles for specific services.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
No.
Are there other deductibles for specific services?
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
$5,000 Individual/$10,000 Family
What is the out-of-pocket limit for this plan?
Premiums, balance-billing charges, and health care this plan doesn't cover.
What is not included in the out-of-pocket limit?
Coverage for: Individual/Family | Plan Type: HMO 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
H 41
Will you pay less if you use a network provider? Yes. See www.bcbstx.com/go/bahmo or call 1-877-299-2377 for a list of Participating Providers.
Page 1 of 6
Do you need a referral to see a specialist?
may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
to a 30-day supply at retail (or a 90day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Cost
for insulin included in the drug list will not exceed $25 per prescription for a 30day supply, regardless of the amount or type of insulin needed to fill the prescription.
*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023
Page 2 of 6 All copayment and coinsurance costs
in this chart are after
What You Will Pay Common Medical Event Services You May Need Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Primary care visit to treat an injury o r illness No Charge after deductible Not Covered Virtual visits are available. See your benefit booklet* for details. Specialist visit No Charge after deductible Not Covered Referral required If you visit a health care provider’s office or clinic Preventive care/screening/ immunization No Charge; deductible does not apply Not Covered
Diagnostic test (x-ray, blood work) No Charge after deductible Not Covered If you have a test Imaging (CT/PET scans, MRIs) No Charge after deductible Not Covered None Preferred generic drugs No Charge after deductible Not Covered Non-preferred generic drugs No Charge after deductible Not Covered Preferred brand drugs No Charge after deductible Not Covered Non-preferred brand drugs No Charge after deductible Not Covered Preferred specialty drugs No Charge after deductible Not Covered If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rx- drugs/drug-lists/drug-lists Non-preferred specialty drugs No Charge after deductible Not Covered Limited
Facility fee (e.g., ambulatory surgery center) No Charge after deductible Not Covered If you have outpatient surgery Physician/surgeon fees No Charge after deductible Not Covered For Outpatient Infusion Therapy, see your benefit booklet* for details. Emergency room care No Charge after deductible No Charge after deductible None Emergency medical transportation No Charge after deductible No Charge after deductible If you need immediate medical attention Urgent care No Charge after deductible Not Covered None If you have a hospital stay Facility fee (e.g., hospital room) No Charge after deductible Not Covered None 42
shown
your deductible has been met, if a deductible applies.
You
Sharing
What You Will Pay
Cost sharing does not apply to certain preventive services. Depending on the type of services, deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Does not include
*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023
Page 3 of 6
Common Medical Event Services You
Need Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Physician/surgeon feesNo Charge after deductible Not Covered Outpatient services No Charge after deductible Not Covered None If
need mental health, behavioral health, or substance abuse services Inpatient services No Charge after deductible Not Covered None Office visits No Charge after deductible Not Covered Childbirth/delivery professional services No Charge after deductible Not Covered
pregnant Childbirth/delivery facility services No Charge after deductible Not Covered
Home health care No Charge after deductible Not Covered None Rehabilitation services No Charge after deductible Not Covered Habilitation services No Charge after deductible Not Covered None Skilled nursing care No Charge after deductible Not Covered 60 day maximum per calendar year. Durable medical equipment No Charge after deductible Not Covered None If
other special health needs Hospice services No Charge after deductible Not Covered None Children’s eye exam No Charge after deductible Not Covered Eye screenings
refractions.
ages
and
Children’s glasses Not Covered Not Covered If your child needs dental or eye care Children’s dental check-up Not Covered Not Covered None 43
May
you
If you are
you need help recovering or have
only.
One visit per year for members
17
younger.
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Long-term care
Non-emergency care when traveling outside the U.S.
Weight loss programs
Children's glasses Cosmetic surgery
Dental care (Adult)
Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed)
Acupuncture
Bariatric surgery
Children's dental check-up
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Routine eye care (AdultOne visit every two years for members ages 18 and older)
Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)
Infertility treatment (Invitro not covered)
Chiropractic care (Preauthorization required)
Private-duty nursing (Only when ordered or authorized by the Primary Care Physician)
Hearing aids (Limited to one hearing aid per ear every 36 months)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com . For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform . For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov . Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html .
Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
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Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-877-299-2377.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.
Chinese ( 中文 ) : 如果需要中文的帮助， 请拨 打 这 个号 码 1-877-299-2377 .
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
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This
Treatments
(deductibles, copayments
coinsurance)
pay under
examples
coverage. The plan’s overall deductible $5,000 Specialist $0 Hospital (facility) $0 Other $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $5,000 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,060 The plan’s overall deductible $5,000 Specialist $0 Hospital (facility) $0 Other $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $2,300 Copayments $300 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $2,620 The plan’s overall deductible $5,000 Specialist $0 Hospital (facility) $0 Other $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test ( x-ray ) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $2,800 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,800 The plan
EXAMPLE covered services.
(9
of
Managing Joe’s Type 2 Diabetes (a year of routine in-network
of
controlled condition) Mia’s Simple Fracture (in-network emergency room visit and
care) 46
About these Coverage Examples:
is not a cost estimator.
amounts
and
and excluded services under the plan. Use this information to compare the portion of costs you might
different health plans. Please note these coverage
are based on self-only
would be responsible for the other costs of these
Peg is Having a Baby
months
in-network pre-natal care and a hospital delivery)
care
a well-
follow up
bcbstx.com 47
bcbstx.com 48
ABOUT TELEHEALTH
Telehealth provides 24/7/365 access to board-certified doctors via telephone or video consultations that can diagnose, recommend treatment and prescribe medication. Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.
For full plan details, please visit your benefit website: www.txescbenefits.com
Alongside your medical coverage is access to quality telehealth services through MDLIVE. Connect anytime day or night with a board-certified doctor via your mobile device or computer. While MDLIVE does not replace your primary care physician, it is a convenient and cost-effective option when you need care and:
• Have a non-emergency issue and are considering a convenience care clinic, urgent care clinic or emergency room for treatment
• Are on a business trip, vacation or away from home
• Are unable to see your primary care physician
When to Use MDLIVE:
At a cost that is the same or less than a visit to your physician, use telehealth services for minor conditions such as:
• Sore throat
• Headache
• Stomachache
• Cold
• Flu
• Allergies
• Fever
• Urinary tract infections
Do not use telemedicine for serious or life-threatening emergencies.
Registration is Easy
• Register with MDLIVE so you are ready to use this valuable service when and where you need it.
• Online – www.mdlive.com/fbs
• Phone – 888-365-1663
• Mobile – download the MDLIVE mobile app to your smartphone or mobile device
• Select –“MDLIVE as a benefit” and “FBS” as your Employer/Organization when registering your account.
Check
with your employer to see if this benefit is available at no cost to you Telehealth Employee and Family $10.00
EMPLOYEE
49
Telehealth MDLIVE
BENEFITS
