Академический Документы
Профессиональный Документы
Культура Документы
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |Plan Type: PPO
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
document at www.bcbstx.com/member/policy-forms/2017 or by calling 1-800-521-2227.
2 of 8
Your cost if you use an
Your cost if you use a
Common Medical Event Services You May Need Out-of-Network Limitations & Exceptions
Network Provider
Provider
If you need drugs to treat Retail - $15/$20 copay 50% coinsurance plus $20 Lower copay applies at preferred Network
your illness or condition Generic drugs Mail - $45 copay copay pharmacies. One copay per 30-day supply -
More information about Preferred brand drugs Retail - $30/$40 copay 50% coinsurance plus $40 up to a 90-day supply for generic and brand
Mail - $90 copay copay drugs, up to a 30-day supply for specialty
prescription drug
drugs. Payment of the difference between
coverage is available at Retail - $45/$55 copay 50% coinsurance plus $55 the cost of a brand name drug and a generic
https://www.myprime.c Non-preferred brand drugs Mail - $135 copay copay may also be required if a generic drug is
om/content/dam/prime
available. Certain women's preventive
/memberportal/forms/A Specialty drugs $45/$55 copay 50% coinsurance
services will be covered with no cost to the
uthorForms/IVL/2017/2
member.
017_TX_3T_EX.pdf
Facility fee (e.g., ambulatory Elective abortion is not covered except in
If you have outpatient 20% coinsurance 40% coinsurance limited circumstances. 50% penalty for
surgery center)
surgery failure to preauthorize Out-of-Network
(not to exceed $500).
Physician/surgeon fees 20% coinsurance 40% coinsurance Termination of pregnancy is not covered
except in limited circumstances. 50%
penalty for failure to preauthorize
Out-of-Network (not to exceed $500).
If you need immediate $400 copay/visit plus $400 copay/visit plus Copay is charged in addition to the overall
Emergency room services
medical attention 20% coinsurance 20% coinsurance deductible and is waived if admitted.
Emergency medical
20% coinsurance 20% coinsurance
transportation ---none---
Urgent care $75 copay/visit 40% coinsurance
If you have a hospital Facility fee (e.g., hospital $250 penalty for failure to preauthorize
20% coinsurance 40% coinsurance
stay room) Out-of-Network.
Physician/surgeon fee 20% coinsurance 40% coinsurance ---none---
3 of 8
Your cost if you use an
Your cost if you use a
Common Medical Event Services You May Need Out-of-Network Limitations & Exceptions
Network Provider
Provider
$30 copay for office visits
Mental/behavioral health
or 20% coinsurance for 40% coinsurance
outpatient services
other outpatient services
Mental/behavioral health Outpatient: Preauthorization required for
If you have mental 20% coinsurance 40% coinsurance psychological testing, neuropsychological
health, behavioral health, inpatient services
testing, electroconvulsive therapy, repetitive
or substance abuse $30 copay for office visits
Substance use disorder transcranial magnetic stimulation, and
needs or 20% coinsurance for 40% coinsurance
outpatient services intensive outpatient treatment.
other outpatient services
Substance use disorder
20% coinsurance 40% coinsurance
inpatient services
$30 copay Primary care/
Copay applies to first prenatal visit (per
If you are pregnant Prenatal and postnatal care $50 copay/Specialist for 40% coinsurance
pregnancy)
initial visit
Delivery and all inpatient
20% coinsurance 40% coinsurance ---none---
services
If you need help Home health care 20% coinsurance 40% coinsurance
recovering or have other 60 visit maximum per benefit period.
special health needs
Rehabilitation services 20% coinsurance 40% coinsurance 35 visit maximum per benefit period,
Habilitation services 20% coinsurance 40% coinsurance including chiropractic.
Skilled nursing care 20% coinsurance 40% coinsurance 25 day maximum per benefit period. $250
penalty for failure to preauthorize
Out-of-Network.
Durable medical equipment 20% coinsurance 40% coinsurance ---none---
Hospice service 20% coinsurance 40% coinsurance $250 penalty for failure to preauthorize
Out-of-Network.
4 of 8
Your cost if you use an
Your cost if you use a
Common Medical Event Services You May Need Out-of-Network Limitations & Exceptions
Network Provider
Provider
Eye exam No Charge No Charge One visit per year. Reimbursed up to $30
If your child needs
Out-of-Network. See benefit booklet for
dental or eye care
network details.
Glasses No Charge No Charge One pair of glasses per year. Up to $150
In-Network. Reimbursed up to $45
frames/$25 single vision lenses
Out-of-Network. See benefit booklet for
network details.
Dental check-up 30% coinsurance 30% coinsurance Two visits per year. See benefit booklet for
network details
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.)
Chiropractic care Hearing aids (Limited to one for each ear every Routine foot care (Only covered in connection
Cosmetic surgery (Only covered for the three years) with diabetes, circulatory disorders of the lower
correction of congenital deformities or for Infertility treatment (Diagnosis covered but extremities, peripheral vascular disease, peripheral
conditions resulting from accidental injuries, scars, treatment and Invitro not covered) neuropathy, or chronic arterial or venous
tumors or diseases. when medically necessary.) insufficiency)
6 of 8
About These Coverage Having a baby Managing type 2 diabetes
(normal delivery) (routine maintenance of a well-controlled
Examples: condition)
These examples show how this plan might cover n Amount owed to providers: $7,540 n Amount owed to providers: $5,400
medical care in given situations. Use these n Plan pays $4,820 n Plan pays $3,120
examples to see, in general, how much financial n Patient pays $2,720 n Patient pays $2,280
protection a sample patient might get if they are
Sample care costs: Sample care costs:
covered under different plans.
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
This is not a Hospital charges (baby) $900 Office Visits and Procedures $700
Education $300
cost Anesthesia $900 Laboratory tests $100
estimator. Laboratory tests $500 Vaccines, other preventive $100
Prescriptions $200 Total $5,400
Dont use these examples to estimate Radiology $200 Patient pays:
your actual costs under the plan. The Vaccines, other preventive $40 Deductibles $1,300
actual care you receive will be different
from these examples, and the cost of Total $7,540 Copays $700
Coinsurance $200
that care also will be different.
Patient pays: Limits or exclusions $80
Deductibles $1,300 Total $2,280
See the next page for important
Copays $20
information about these examples.
Coinsurance $1,200
Limits or exclusions $200
Total $2,720
7 of 8
Questions and answers about Coverage Examples:
What are some of the assumptions What does a Coverage Example Can I use Coverage Examples to
behind the Coverage Examples? show? compare plans?
Costs dont include premiums. For each treatment situation, the Coverage Yes. When you look at the Summary of
Sample care costs are based on national Example helps you see how deductibles,
Benefits and Coverage for other plans, youll
averages supplied by the U.S. Department of copayments, and coinsurance can add up. It
find the same Coverage Examples. When you
Health and Human Services, and arent specific also helps you see what expenses might be left up
compare plans, check the Patient Pays box
to a particular geographic area or health plan. to you to pay because the service or treatment
in each example. The smaller that number,
The patients condition was not an excluded isnt covered or payment is limited.
the more coverage the plan provides.
or preexisting condition.
All services and treatments started and ended Does the Coverage Example Are there other costs I should
in the same coverage period. predict my own care needs? consider when comparing plans?
There are no other medical expenses for any Yes. An important cost is the premium you
member covered under this plan.
No. Treatments shown are just examples. The
care you would receive for this condition could pay. Generally, the lower your premium, the
Out-of-pocket expenses are based only on be different based on your doctors advice, more youll pay in out-of-pocket costs, such
treating the condition in the example. your age, how serious your condition is, and as copayments, deductibles, and coinsurance.
The patient received all care from in-network many other factors. You should also consider contributions to
providers. If the patient had received care accounts such as health savings accounts
from out-of-network providers, costs would Does the Coverage Example (HSAs), flexible spending arrangements (FSAs)
have been higher. or health reimbursement accounts (HRAs)
predict my future expenses?
that help you pay out-of-pocket expenses.
No. Coverage Examples are not cost
estimators. You cant use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers charge,
and the reimbursement your health plan
allows.