1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018. SM. : Blue Advantage Silver HMO 205 - Two $15 PCP Visits Coverage for: Individual/Family Plan Type: HMO. 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 2018 or by calling 1-888-697-0683. 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 Reports-and-Other-Resources/ or call 1-855-756-4448 to request a copy.
2 Important Questions Answers Why This Matters: What is the overall $0 Generally, you must pay all of the costs from providers up to the deductible amount before deductible? 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. Are there services covered No. You will have to meet the deductible before the plan pays for any services. before you meet your deductible? Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of-pocket $2,450 Individual/$4,900 Family. The out-of-pocket limit is the most you could pay in a year for covered services. If you have limit for this plan? 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.
3 What is not included in the Premiums and health care this Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? plan does not cover. Will you pay less if you use Yes. For a list of Participating This plan uses a provider network. You will pay less if you use a provider in the plan's network. a network provider? providers please call You will pay the most if you use an out-of-network provider, and you might receive a bill from 1-888-697-0683 or see www. 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. Do you need a referral to Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if see a specialist?
4 You have a referral before you see the specialist. 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 1 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 Participating Provider Non-Participating Limitations, Exceptions, & Other Important Services You May Need Medical Event (You will pay the least) Provider (You will pay the Information most). Primary care visit to treat an $15/visit Not Covered First two office visits are at copayment injury or illness amount; coinsurance apply for subsequent visits. If you visit a health care Specialist visit 40% coinsurance Not Covered None provider's office or clinic Preventive care/screening/ No Charge Not Covered You may have to pay for services that aren't immunization preventive.
5 Ask your provider if the services you need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood Hospital 40% Not Covered work) coinsurance Non-Hospital 30%. coinsurance If you have a test Preauthorization required; no member penalty. Imaging (CT/PET scans, MRIs) Hospital 40% Not Covered coinsurance Non-Hospital 30%. coinsurance If you need drugs to Preferred generic drugs Retail Preferred Not Covered treat your illness or Participating - No Charge condition Participating Limited to a 30-day supply at retail (or a $10/prescription 90-day supply at a network of select retail More information about Mail - No Charge prescription drug pharmacies). Up to a 90-day supply at mail Non-preferred generic drugs Retail Preferred Not Covered order. Specialty drugs limited to a 30-day coverage is available at Participating - supply. Payment of the difference between $10/prescription the cost of a brand name drug and a generic com/content/dam/.
6 Non-Preferedd may also be required if a generic drug is prime/memberportal/. $20/prescription available. forms/AuthorForms/. Mail - $30/prescription HIM/2018/TX_6T_EX. pdf 2 of 7. What You Will Pay Common Participating Provider Non-Participating Limitations, Exceptions, & Other Important Services You May Need Medical Event (You will pay the least) Provider (You will pay the Information most). Preferred brand drugs Retail Preferred Not Covered Participating 30% coinsurance Participating 35% coinsurance Mail: 30% coinsurance Non-preferred brand drugs Retail Preferred Not Covered Participating 35% coinsurance Participating 40% coinsurance Mail: 35% coinsurance Preferred specialty drugs 45% coinsurance Not Covered Non-Preferred specialty drugs 50% coinsurance Not Covered Facility fee ( , ambulatory Hospital $100/visit plus Not Covered surgery center) 40% coinsurance Elective abortion is not covered except in If you have outpatient Non-Hospital - $100/visit limited circumstances.
7 Preauthorization surgery plus 30% coinsurance required; no member penalty. Physician/surgeon fees $50/visit plus 40% Not Covered coinsurance Emergency room care $500/visit plus 40% $500/visit plus 40%. Copayment is waived if admitted. coinsurance coinsurance If you need immediate Emergency medical 40% coinsurance 40% coinsurance medical attention transportation None Urgent care $25/visit Not Covered Facility fee ( , hospital $250/admit plus Not Covered If you have a hospital Preauthorization required; no member penalty. room) 40% coinsurance stay Physician/surgeon fees 40% coinsurance Not Covered None If you need mental Outpatient services 40% coinsurance Not Covered health, behavioral Inpatient services $250/admit plus 40% Not Covered Preauthorization required; no member penalty. health, or substance coinsurance abuse services 3 of 7. What You Will Pay Common Participating Provider Non-Participating Limitations, Exceptions, & Other Important Services You May Need Medical Event (You will pay the least) Provider (You will pay the Information most).
8 Office visits $15/visit Not Covered Copayment applies to first prenatal visit (per Childbirth/delivery professional 40% coinsurance Not Covered pregnancy) if one of first two office visits per services benefit period; coinsurance apply for Childbirth/delivery facility $250/admit plus 40% Not Covered subsequent visits. Cost sharing does not services coinsurance apply to certain preventive services. If you are pregnant Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC ( ultrasound). Inpatient: Preauthorization required; no member penalty. Home health care 40% coinsurance Not Covered 60 visit maximum per calendar year. Rehabilitation services 40% coinsurance Not Covered 35 visit maximum per calendar year combined If you need help with Chiropractic care. Preauthorization Habilitation services 40% coinsurance Not Covered recovering or have required; no member penalty.
9 Other special health Skilled nursing care 40% coinsurance Not Covered 25 day maximum per calendar year. needs Durable medical equipment 40% coinsurance Not Covered Preauthorization required; no member penalty. Hospice services 40% coinsurance Not Covered None Children's eye exam No Charge; Not Covered One visit per year. *See benefit booklet for deductible does not apply details. If your child needs Children's glasses No Charge; Not Covered One pair of glasses per year. *See benefit dental or eye care deductible does not apply booklet for details. Children's dental check-up Not Covered Not Covered None *For more information about limitations and exceptions, see the plan or policy document at 4 of 7. 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.)
10 Abortions (Except where a pregnancy is the result Dental Care (Adult and Child) Private-duty nursing (Unless medically necessary). of rape or incest, or for a pregnancy which, as Infertility treatment (Diagnosis and treatment Routine eye care (Adult). certified by a physician, places the woman in covered; in vitro not covered) Routine foot care (Except in connection with danger of death unless an abortion is performed) Long-term care diabetes, circulatory disorders of the lower Acupuncture Non-emergency care when traveling outside the extremities, peripheral vascular disease, peripheral Bariatric surgery neuropathy, or chronic arterial or venous Cosmetic surgery (Except for the correction of insufficiency). congenital deformities or for conditions resulting Weight loss programs from accidental injuries, scars, tumors or diseases. When medically necessary.).