Our goal is to serve your health insurance needs through all of life s changes. If you have any questions, our team stands ready to help.
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![September 2013 Dear [First Name] [Last Name], Thank you for your trust in Blue Cross and Blue Shield of Texas (BCBSTX), and in the strength of the health coverage and customer service we provide you.](/docs-images/84/90564927/images/1-0.jpg "You will soon have the opportunity to select a new plan from all of our available options.")
1 September 2013 Dear [First Name] [Last Name], Thank you for your trust in Blue Cross and Blue Shield of Texas (BCBSTX), and in the strength of the health coverage and customer service we provide you. You will soon have the opportunity to select a new plan from all of our available options. To help ensure a smooth transition to an ACA compliant health insurance policy, BCBSTX will recommend a plan that is similar to the one you currently have to replace your current coverage at the time of your renewal. You can select this or any of BCBSTX s available plans, which are included as an attachment, to meet your company s health care needs. (Please note that BCBSTX is awaiting final product approval from the Texas Department of Insurance, and we are unable to provide final product details at this time. However, your renewal packet will contain complete product information.) As you may know, all non-grandfathered health insurance plans with renewal dates on or after January 1, 2014, must comply with the requirements of the Affordable Care Act (ACA) at the time of their renewal. This means that the health insurance plan you currently have with us will be discontinued on or after your renewal date Your next steps: View your choices in the renewal packet that will be sent at least 60 days before your renewal date. Choose a new plan that is best for your company. Contact your broker directly or call a BCBSTX representative if you have questions. Our goal is to serve your health insurance needs through all of life s changes. If you have any questions, our team stands ready to help. Sincerely, Blue Cross and Blue Shield of Texas
2 Portfolio Effective 1/1/14 PPO Plans Plan Out-of Pocket RM01 $250/$750 $15 90/70 $1,250/$3,750 $15/30/45 RM02 $500/$1,500 $15 90/70 $2,500/$7,500 $15/30/45 RM03 $500/$1,500 $15 80/60 $2,500/$7,500 $15/30/45 RM04 $500/$1,500 $20 80/60 $3,000/$9,000 $20/35/50 RM05 $750/$2,250 $20 80/60 $3,750/$11,250 $15/30/45 RM06 $1,000/$3,000 $20 100/70 $1,500/$4,500 $15/30/45 RM07 $1,000/$3,000 $20 80/60 $3,500/$10,500 $15/30/45 RM08 $1,000/$3,000 $25 90/70 $4,000/$12,000 $15/30/45 RM09 $1,000/$3,000 $25 80/60 $4,000/$12,000 $20/35/50 RM10 $1,000/$3,000 $25 75/50 $5,000/$12,700 $20/40/60 RM11 $1,000/$3,000 $30 80/60 $5,000/$12,700 $20/35/50 RM14 $1,500/$4,500 $20 80/60 $4,500/$12,700 $15/30/45 RM15 $1,500/$4,500 $25 75/50 $4,500/$12,700 $15/40/55 RM16 $1,500/$4,500 $30 80/60 $4,500/$12,700 $20/35/50 RM17 $1,500/$4,500 $30 75/50 $5,500/$12,700 $20/40/60 RM18 $2,000/$6,000 $20 80/60 $5,000/$12,700 $15/40/55 RM19 $2,000/$6,000 $25 75/50 $5,000/$12,700 $15/40/55 RM20 $2,000/$6,000 $30 75/50 $6,000/$12,700 $20/40/60 RM22 $2,500/$7,500 $25 80/60 $5,500/$12,700 $10/40/60 RM23 $2,500/$7,500 $25 70/50 $5,500/$12,700 $20/40/60 RM24 $2,500/$7,500 $30 70/50 $6,350/$12,700 $20/40/60 RM25 $3,000/$9,000 $30 100/70 $3,500/$10,500 $10/40/60 RM26 $3,000/$9,000 $40 70/50 $6,350/$12,700 $20/40/60 RM28 $4,000/$8,000 $40 70/50 $6,350/$12,700 $20/40/60 RM29 $4,000/$8,000 $40 50/50 $6,350/$12,700 $20/40/60 RM30 $5,000/$10,000 $30 100/70 $5,500/$11,500 $10/40/60 RM31 $5,000/$10,000 $40 80/60 $6,350/$12,700 $20/40/60 RM32 $5,000/$10,000 $40 70/50 $6,350/$12,700 $20/40/60 RM36 $2,000/$6,000 $30 100/80 $2,500/$7,500 $20/35/50 RM37 $4,000/$12,000 $30 100/70 $4,500/$12,700 $20/40/60 RM38 $2,500/$7,500 $25 100/70 $3,000/$9,000 $15/30/45 RM40 $6,350/$12,700 $25 100/70 $6,350/$12,700 $15/40/60 RM42 $1,000/$3,000 $20 80/60 $4,000/$12,000 $15/30/45 RM43 $1,000/$3,000 $30 80/60 $4,000/$12,000 $25/35/50
3 Plan Out-of Pocket RM44 $2,000/$6,000 $25 90/70 $5,000/$12,700 $15/30/45 RM45 $3,000/$9,000 $45 70/50 $6,350/$12,700 $20/40/60 RMB1 $1,000/$3,000 $20 80/60 $4,000/$12,000 $15/40/55 RMB2 $2,500/$7,500 $30 80/60 $6,350/$12,700 $20/40/60 RMB3 $3,000/$9,000 $30 80/60 $6,000/$12,700 $10/40/60 RMB4 $5,000/$10,000 $40 70/50 $6,350/$12,700 $20/40/60 Four Tier Rx Plans Plan Enhanced Rx Plans Out-of Pocket RMF1 $3,000/$9,000 $30 100/70 $3,500/$10,500 $8/35/75/150 RMF2 $1,000/$3,000 $20 100/70 $1,500/$4,500 $8/35/75/150 RMF3 $2,000/$6,000 $20 80/60 $5,000/$12,700 $8/35/75/150 RMF4 $3,000/$9,000 $40 70/50 $6,350/$12,700 $8/35/75/150 RMF5 $1,000/$3,000 $25 80/60 $4,000/$12,000 $8/35/75/150 RMF7 $1,500/$4,500 $30 80/60 $4,500/$12,700 $10/35/75/150 RMF8 $2,000/$6,000 $20 80/60 $5,000/$12,700 $10/35/75/150 Plan /Family OOP Max RME01 $500/$1,500 $15 90/70 $2,500/$7,500 $15/30/45 RME02 $500/$1,500 $20 80/60 $3,000/$9,000 $20/35/50 RME03 $750/$2,250 $20 80/60 $3,750/$11,250 $15/30/45 RME04 $1,000/$3,000 $20 100/70 $1,500/$4,500 $15/30/45 RME05 $1,000/$3,000 $20 80/60 $3,500/$10,500 $15/30/45 RME06 $1,000/$3,000 $25 80/60 $4,000/$12,000 $20/35/50 RME07 $1,000/$3,000 $30 80/60 $5,000/$12,700 $20/35/50 RME08 $1,500/$4,500 $30 80/60 $4,500/$12,700 $20/35/50 RME09 $2,000/$6,000 $30 100/80 $2,500/$7,500 $20/35/50 RME10 $3,000/$9,000 $30 100/70 $3,500/$10,500 $10/40/60 RME11 $3,000/$9,000 $40 70/50 $6,350/$12,700 $20/40/60
4 HSA Embedded Plans Family RMH1 $2,500/$5,000 $5,000/$10,000 / RMH2 $3,000/$6,000 $6,000/$12,000 / RMH3 $5,000/$10,000 $10,000/$20,000 / RMH6 $3,500/$7,000 $7,000/$14,000 / RMH7 $2,500/$5,000 $5,000/$10,000 / RMH8 $4,000/$8,000 $8,000/$16,000 / RMH9 $3,500/$7,000 $7,000/$14,000 / OOP Max 100/70 $2,500/$5, after 100/70 $3,000/$6, after 100/70 $5,000/$10, after 80/60 $5,000/$10, aft 80/60 $5,000/$10, aft 100/70 $4,000/$8, after 100/70 $3,500/$7, after
5 HSA Aggregate Plans Family RMH4 $1,500/$3,000 $3,000/$6000 / 80/60 $4,500/$9, after RMH5 $3,000/$6,000 $6,000/$12,000 / 100/70 $3,000/$6, after BlueEdge HCA (Non-Integrated Drug Plans) HCA Funding R9104 N/A $500/$1,000 $2000/$ /60 $4500/$9000 $20/40/60 BlueEdge HCA (Integrated Drug Plans) HCA Funding /Family R9203R N/A $750/$1,500 $1,500/$3,000 80/60 $3,750/$7, after R9502R N/A $500/$1,000 $5,000/$10, /70 $5,500/$11, after
6 HMO Blue Texas Plans Visit In-Hospital R Plan 29 $20/$20 $500 per R Plan 31 $25/$25 $750 per R Plan 32 $30/$30 $1,000 per R Plan 33 $10/$30 $350 per R Plan 34 $15/$35 $500 per R Plan 35 $20/$45 $600 per R Plan 36 $25/$45 $1,000 per R Plan 37 $30/$50 $1,250 per R Plan 38 $35/$55 $1,250 per R Plan 39 $40/$60 $1,500 per Emergency Room PDP $75 per visit $1,500/$3,000 $10/25/40 $75 per visit $2,500/$5,000 $15/30/45 $75 per visit $3,000/$6,000 $20/35/50 $100 per visit $1,500/$3,000 $10/25/40 $125 per visit $2,000/$4,000 $15/30/45 $150 per visit $2,500/$5,000 $15/30/45 $150 per visit $3,000/$6,000 $20/35/50 $150 per visit $3,000/$6,000 $20/40/60 $150 per visit $4,000/$8,000 $20/40/60 $150 per visit $4,000/$8,000 $20/40/60 HMO Riders Option Description DM3 DME no copay DM4 DME 20 copay SHO Speech and Hearing Option IVO In Vitro Fertilization Option IM4 Inpatient Mental covered same as any other illness O2 Vision Exam Only - $10 copay every 12 months; Lens Exam - $20 every 12 months no hardware 6 Vision Services Eye Exam - $3 copay every 12 months; varying copays for frames and lenses coverage every 12 months IC Vision Services Eyeglass Exam is $5 copay every 12 months; Lens Exam included in cost of lenses w/exam every 12 months. Standard frame $5 copay every 24 months and nonstandard frames have higher copays. OC Vision Services Eyeglass Exam is $10 copay every 12 months; Lens Exam included in cost of lenses w/exam every 12 months. Standard frame $15 copay every 24 months and nonstandard frames have higher copays.
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