Market Segment Guide Effective 1/1/13
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1 Market Segment Guide Effective 1/1/13 1 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
2 2 PPO Plans BlueChoice Network
3 3 00/$ %/50% $1500 RM17 /35/50 $1500 RM16 $15/40/55 75%/50% $1500 RM15 $1500 RM14 /35/50 00/$ RM11 00/$ %/50% 0 RM10 /35/50 0 RM09 90%/70% 0 RM08 00/00 0 RM07 $0/$ RM06 $750 RM05 /35/50 00/00 0 RM04 00/00 $15 0 RM03 00/00 90%/70% $15 0 RM02 0/00 90%/70% $15 0 RM01 Pharmacy Coins Stoploss Coins % ER Urgent Care Office Ded Comb Health Plan #
4 4 00/00 75%/50% $65 $7500 RM33 00/00 70%/50% $65 00 RM32 $3500/$7000 $65 00 RM31 $10/40/60 $0/00 00 RM30 $7500/$ %/50% $65 00 RM29 00/00 70%/50% $65 00 RM28 00/00 70%/50% $65 00 RM26 $10/40/60 $0/00 00 RM25 00/$ %/50% 00 RM24 //$60 70%/50% 00 RM23 $10/40/60 00 RM22 00/$ %/50% 00 RM20 $15/40/55 75%/50% 00 RM19 $15/40/55 00 RM18 Pharmacy Coins Stoploss Coins % ER Urgent Care Office Ded Comb Health Plan #
5 Health Plan # Ded Comb Office Urgent Care ER Coins % Coins Stoploss Pharmacy RM34 00 $65 75%/50% 00/00 RM %/80% $0/$8000 /35/50 RM37 00 $0/00 RM38 00 $0/00 RM40 $7500 $0/00 $15/40/60 RM41 00 $0/00 $15/40/60 RM42 0 RM43 0 /35/50 RM %/70% RM45 00 $70 70%/50% 00/00 RMB1 ± 0 $15/40/55 RMB2 ± 00 00/$8000 RMB3 00 $10/40/60 RMB4 00 $65 70%/50% 00/00 ± applies to the Physician Office Visit Only and Lab & X-Ray paid after coinsurance applies to the Physician Office Visit Only and Lab & X-Ray paid after deductible and coinsurance 5
6 6 BlueChoice PPO Four Tier Rx Plans BlueChoice Network
7 Health Plan # Ded Comb Office Urgent Care ER Coins % Coins Stoploss Pharmacy* RMF1 00 $0/00 $8/35/75/150 RMF2 0 $0/$8000 $8/35/75/150 RMF3 00 $8/35/75/150 RMF4 00 $65 70%/50% 00/00 $8/35/75/150 RMF5 0 $8/35/75/150 RMF $65 70%/50% 00/00 $10/35/75/150 RMF7 $ $10/35/75/150 RMF $10/35/75/150 *Preferred Drug List 1 applies to all Middle Market Plans except Four Tier Rx Plans which are subject to Preferred Drug List 2. + applies to the physician office visit only. 7
8 Enhanced Rx Plans BlueChoice Network Members electing to purchase Preferred/Non-Preferred Brand Name Drugs when Brand Medically Necessary IS NOT indicated and a Generic equivalent IS available, will be required to pay: The difference between the cost of the Generic and Preferred/Non-Preferred Brand Name Drug, PLUS the Preferred Brand Name ment Amount If Brand Medically Necessary IS indicated on the prescription, the member will pay the Preferred or Non-Preferred Brand Name ment 8
9 9 00/00 70%/50% 00 RME11 $10/40/60 $0/00 00 RME10 /35/50 $0/$ %/80% 00 RME09 /35/50 $1500 RME08 /35/50 00/$ RME07 /35/50 0 RME06 00/00 0 RME05 $0/$ RME04 $750 RME03 /35/50 00/00 0 RME02 00/00 90%/70% $15 0 RME01 Pharmacy Coins Stoploss Coins % Office Ded Comb Health Plan #
10 Health Savings Account* Plans BlueChoice Network *Please be reminded that Health Savings Account (HSA s) have tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products. 10
11 Embedded Deductible Plans Health Plan # Ded Individual Ded Family Office Coins % Out of Pocket Maximum* Indiv/Family Pharmacy RMH1 00/00 00/00 Ded & Coins 00/00 100% after cal year deductible RMH2 $6000/$12000 Ded & Coins 100% after cal year deductible RMH3 00/00 00/000 Ded & Coins 00/00 100% after cal year deductible RMH6 $3500/$7000 $7000/$14000 Ded & Coins 00/00 80% after cal year deductible RMH7 00/00 00/00 Ded & Coins 00/00 80% after cal year deductible RMH8 00/$8000 $8000/$16000 Ded & Coins 00/$ % after cal year deductible RMH9 $3500/$7000 $7000/$14000 Ded & Coins $3500/$ % after cal year deductible *Deductible plus Coinsurance Stoploss equals Out of Pocket Maximum The individual deductible amount must be satisfied by every participant covered, each calendar year. If dependents are covered, all charges applied to the individual deductible amount will be applied toward the family deductible amount. When the family deductible is reached, no further individual deductibles will have to be satisfied for the remainder of that calendar year. No participant will contribute more than the individual deductible amount to the family deductible amount. 11
12 Aggregate Deductible Plans Health Plan # Ded Individual Ded Family Office Coins % Out of Pocket Maximum* Indiv/Family Pharmacy RMH4 $1500/00 Ded & Coins 00/$ % after cal year deductible RMH5 $6000/$12000 Ded & Coins *Deductible plus Coinsurance Stoploss equals Out of Pocket Maximum 100% after cal year deductible If family coverage is selected, the family deductible amount must be satisfied before any benefits are available under the HSA plan. The family deductible amount may be satisfied by one participant or a combination of two or more participants. 12
13 13 BlueEdge HCA
14 BlueEdge HCA (Non-Integrated Drug Plans) Health Plan # Office HCA Funding* Indiv/Family Ded Indiv/Family Coins % Coins Stoploss Indiv/Family Pharmacy R9104 N/A 0/0 00/00 00/00 R9501 N/A 0/00 $3500/$ %/70% $3500/$7000 *Healthcare account is funded by the employer 14
15 BlueEdge HCA (Integrated Drug Plans) Health Plan # Office HCA Funding* Indiv/Family Ded Indiv/Family Coins % Coins Stoploss Indiv/Family Pharmacy R9203R N/A $750/$1500 $1500/00 $1500/00 80% after cal yr ded R9502R N/A 0/0 00/00 $0/$0 100% after cal yr ded *Healthcare account is funded by the employer 15
16 16 HMO Blue Texas Plans
17 Health Plan # Office Visit In-Hospital ER Out of Pocket Maximum PDP RPlan 29 PCP/ Specialist 0 per admission $75 per visit $1500/00 PD10 $10/25/40 RPlan 31 PCP/ Specialist $750 per admission $75 per visit 00/00 PD11 RPlan 32 PCP/ Specialist 0 per admission $75 per visit PD12 /35/50 RPlan33 $10 PCP/ Specialist $350 per admission per visit $1500/00 PD10 $10/25/40 RPlan34 $15 PCP/$35 Specialist 0 per admission $125 per visit 00/00 PD11 RPlan35 PCP/ Specialist $600 per admission $150 per visit 00/00 PD11 RPlan36 PCP/ Specialist 0 per admission $150 per visit PD12 /35/50 RPlan37 PCP/ Specialist $1250 per admission $150 per visit PD13 RPlan38 $35 PCP/ Specialist $1250 per admission $150 per visit 00/$8000 PD13 RPlan39 PCP/$60 Specialist $1500 per admission $150 per visit 00/$8000 PD13 17
18 18 HMO Options
19 Option DM1 DM2 IM4 O2 6 IC OC SH IV DME - No ment DME - 20% ment Inpatient Mental Health - Covered Same As Any Other Illness Vision Exam Only - $10 copay every 12 months; lens exam - every 12 months No Hardware Vision Services Eye exam - $3 copay every 12 months; varying copays for frames/lenses coverage every 12 months Vision Services Eyeglass exam is $5 copay every 12 months; lens exam included in cost of lenses w/exam every 12 months. Standard frames $5 copay every 24 months and non-standard frames have higher copays Vision Services Eyeglass exam is $10 copay every 12 months; lens exam included in cost of lenses w/exam every 12 months. Standard frames $15 copay every 24 months and non-standard frames have higher copays. Speech and Hearing Option In Vitro Fertilization Option Description Attachment DP Domestic Partners 19
20 20 BlueCare Freedom Dental Plans
21 21 50%/0 Deluxe 100/80/50 $1500 /$150 D822 50%/0 Deluxe 100/80/50 0 /$150 D821 0%/$0 Deluxe 100/80/50 0 /$150 D811 50%/00 Deluxe 100/80/50 00 /$150 D803 50%/$1500 Deluxe 100/80/50 00 /$150 D802 50%/$1500 Deluxe 100/80/50 $1500 /$150 D801 50%/$1500 Value 100/80/50 $1500 /$150 D702 50%/0 Value 100/80/50 $1500 /$150 D701 0%/$0 Value 100/80/50 $1500 /$150 D602 0%/$0 Value 100/80/50 0 /$150 D601 0%/$0 Value 100/80/0 $750 /$75 D501 Ortho %/ LifeMax Allocation of Services Benefit Level Annual Max Deductible Indiv/Family Plan
22 Available Health Plan Options: Plan Type Description PPO One PPO, HSA or HCA plan. Dual Option PPO Dual Option PPO (Enhanced Rx) Multiple Option Product (MOP) Triple Option Product Any two plans PPO, HSA or HCA Four Tier Rx Plans can be paired with another Four Tier plan or an HSA. Any two Enhanced Rx PPO plans. Enhanced Rx plans can be paired with an HSA plan. One PPO, HSA or HCA plan (excluding Enhanced Rx and Four Tier Rx Plans) and an HMO plan. Three HSA and/or HCA plans are allowed. One of the following is required: HSA, HCA, RM32, RM33 or RM34. Only one HMO plan is allowed. No Enhanced Rx plans are allowed, unless all plans are Enhanced Rx, HSA plans or combination of both. Four Tier Rx Plans can only be offered with an HSA. 22
23 Available Dental Plan Options: Plan Type Description Dental Select one Dental plan. Dual Option Dental Allowable combinations are: D501 and any other plan D601 and D801, D802, D803, D821 or D822 D602 and D801, D802, D803, D821 or D822 23
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2-50 Market Segment Guide Effective 1/1/13 1 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. 2 BestChoice
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