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Plan Type PPO
Office Visit for Primary Doctor
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$30 Copay
Office Visit for Specialist $50 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $30 Copay
Annual Deductible Individual: $3,250
Separate Prescription Drugs Deductible None
Coinsurance 0% after deductible
Retail Prescription Drugs Generic Drugs: $0 Copay
Preferred Brand Drugs: $35 Copay
Non-preferred Brand Drugs: $75 Copay
Specialty Drugs: $150 Copay
Off Label Prescription Drugs: 0% Coinsurance after deductible
Annual Out-of-Pocket Limit Individual: $3,250
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. This Plan does not cover any services and/or supplies provided to a Member outside the United States if the Member traveled to the location for the purposes of receiving medical services, supplies, or drugs. 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $400 Copay, 0% Coinsurance after deductible
Emergency Ambulance Services 0% Coinsurance after deductible
Urgent Care Facility 0% Coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $0 Copay
Preferred Brand Drugs: $35 Copay
Non-preferred Brand Drugs: $75 Copay
Specialty Drugs: $150 Copay
Off Label Prescription Drugs: 0% Coinsurance after deductible
Separate Prescription Drugs Deductible None
Mail Order Prescription Drugs Generic Drugs: $0 Copay
Preferred Brand Drugs: $70 Copay
Non-preferred Brand Drugs: $150 Copay
Off Label Prescription Drugs: 0% Coinsurance after deductible
Mail Order Supply 90 days supply
Outpatient Coverage
Outpatient Surgery 0% Coinsurance after deductible
Outpatient Lab/X-Ray 0% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 0% Coinsurance after deductible
Outpatient Mental Health $30 Copay
Outpatient Substance Abuse $30 Copay
Outpatient Rehabilitation Services (PT, OT, ST) 0% Coinsurance after deductible, 35 Visit(s) per Benefit Period
Inpatient Coverage
Hospitalization $200 Copay per Stay, 0% Coinsurance after deductible
Skilled Nursing Facility $0 Copay per Stay, 0% Coinsurance after deductible, 25 Days per Benefit Period
Inpatient Mental Health $200 Copay, 0% Coinsurance after deductible
Inpatient Substance Abuse $200 Copay, 0% Coinsurance after deductible
Home Healthcare 0% Coinsurance after deductible, 60 Visit(s) per Benefit Period
Maternity Coverage
Pre & Postnatal Office Visit 0% Coinsurance after deductible
Labor & Delivery Hospital Stay $200 Copay, 0% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children 0% Coinsurance, 1 Visit(s) per Benefit Period
Eye Glasses for Children 0% Coinsurance, 1 Item(s) per Benefit Period
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage 0% Coinsurance after deductible, 35 Visit(s) per Benefit Period
Durable Medical Equipment 0% Coinsurance after deductible
Hospice 0% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) 0% Coinsurance after deductible, 1 Treatment(s) per Benefit Period
Out-of-Network Coverage
Out-of-Network Authorization Required Yes
Out-of-Network Annual Deductible $6500/$19500
Out-of-Network Annual Coinsurance 20% Coinsurance after deductible
Out-of-Network Annual Out-of-Pocket Limit $6500/$19500
Additional Information
A.M. Best Rating A+ as of 12/19/2013
Electronic Signature for Application Available Yes
Policy Form Number UN65-APP/Off-EX
Details and documents about this plan
View Plan Brochure Summary of Benefits & Coverage

The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

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IMPORTANT NOTICES AND DISCLAIMERS

  • THE BENEFITS MATRIX IS A SUMMARY FOR INFORMATIONAL PURPOSES ONLY. REVIEW THE EVIDENCE OF COVERAGE AND INSURANCE POLICY (PLAN CONTRACT) FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS, LIMITATIONS, AND EXCLUSIONS. ONLY THE TERMS AND CONDITIONS OF COVERAGE BENEFITS LISTED IN THE POLICY ARE BINDING.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

CARRIER SPECIFIC NOTICES, DISCLAIMERS, AND FEES

  • 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 Cross and Blue Shield of Texas - Medical expense coverage will not be available until the effective date of the health contract and payment in full of the first month's premium. Applications must be received by Blue Cross and Blue Shield of Texas within the defined enrollment period to be accepted. Effective dates for major medical coverage are available on the 1st of the month only, unless otherwise required by law. This effective date rule does not apply to temporary plans.