2-50 Market Segment Guide Effective 1/1/13
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1 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 2 BestChoice PPO BlueChoice Network
3 00/$ %/50% $1500 RS17 $20/35/50 $1500 RS16 $15/40/55 75%/50% $1500 RS15 $15/30/45 $20 $1500 RS14 $20/35/50 00/$ RS11 Urgent Care 00/$ %/50% 0 RS10 $20/35/50 0 RS09 $15/30/45 90%/70% 0 RS08 $15/30/45 00/00 $20 0 RS07 $15/30/45 $0/$8000 $20 0 RS06 $15/30/45 $20 $750 RS05 $20/35/50 00/00 $20 0 RS04 $15/30/45 $2000/00 $15 0 RS03 $15/30/45 $2000/00 90%/70% $15 0 RS02 $15/30/45 0/$ %/70% $15 0 RS01 Pharmacy Coins Stoploss Coins % ER Office Ded Comb Health Plan # 3
4 00/00 75%/50% $65 $7500 RS33 00/00 70%/50% $65 00 RS32 $3500/$7000 $65 00 RS31 $10/40/60 $0/00 00 RS30 00/00 70%/50% $65 00 RS28 $7500/$ %/50% $65 00 RS29 00/00 70%/50% $65 00 RS26 $10/40/60 00 RS22 $20//$60 70%/50% 00 RS23 00/$ %/50% 00 RS24 $15/40/55 $20 $2000 RS18 $15/40/55 75%/50% $2000 RS19 $10/40/60 $0/00 00 RS25 Urgent Care 00/$ %/50% $2000 RS20 Pharmacy Coins Stoploss Coins % ER Office Ded Comb Health Plan # 4
5 Health Plan # Ded Comb Office Urgent Care ER Coins % Coins Stoploss Pharmacy RS34 00 $65 75%/50% 00/00 RS36 $ %/80% $0/$8000 $20/35/50 RS37 00 $0/00 RS38 00 $0/00 $15/30/45 RS40 $7500 $0/00 $15/40/60 RS41 00 $0/00 $15/40/60 RS42 0 $20 $15/30/45 RS43 0 /35/50 RS44 $ %/70% $15/30/45 RS45 00 $70 70%/50% 00/00 RSB1 ± 0 $20 $15/40/55 RSB2 ± 00 00/$8000 RSB3 00 $10/40/60 RSB4 00 $65 70%/50% 00/00 RL100 0 Ded & Coins Not Available $150 $20/35/50 5 ± 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
6 6 BestChoice PPO Four Tier Rx Plans BlueChoice Network
7 Health Plan # Ded Comb Office Urgent Care ER Coins % Coins Stoploss Pharmacy* RSF1 00 $0/00 $8/35/75/150 RSF2 0 $20 $0/$8000 $8/35/75/150 RSF3 $2000 $20 $8/35/75/150 RSF4 00 $65 70%/50% 00/00 $8/35/75/150 RSF5 0 $8/35/75/150 RSF $65 70%/50% 00/00 $10/35/75/150 RSF7 $ $10/35/75/150 RSF8 $2000 $20+ $10/35/75/150 *Preferred Drug List 1 applies to all Small Group Plans except Four Tier Rx Plans which are subject to Preferred Drug List 2. + applies to the physician office visit only. 7
8 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. 8
9 Embedded Deductible Plans Health Plan # Ded Individual Ded Family Office Coins % Out of Pocket Maximum* Indiv/Family Pharmacy RSH1 00/00 00/00 Ded & Coins 00/00 100% after cal year deductible RSH2 $6000/$12000 Ded & Coins 100% after cal year deductible RSH3 00/00 00/$20000 Ded & Coins 00/00 100% after cal year deductible RSH6 $3500/$7000 $7000/$14000 Ded & Coins 00/00 80% after cal year deductible RSH7 00/00 00/00 Ded & Coins 00/00 80% after cal year deductible RSH8 00/$8000 $8000/$16000 Ded & Coins 00/$ % after cal year deductible RSH9 $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. 9
10 Aggregate Deductible Plans Health Plan # Ded Individual Ded Family Office Coins % Out of Pocket Maximum* Indiv/Family Pharmacy RSH4 $1500/00 Ded & Coins 00/$ % after cal year deductible RSH5 $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. 10
11 BestChoice 100% Contribution Plans* *Employer required to contribute 100% of the premium for each eligible participating employee. 11
12 PPO Plan Health Plan # Ded Combined Office Coins % Coins Stoploss Pharmacy RSE1 00 $0/00 $10/40/60 HSA Plan Health Plan # Ded Individual Ded Family Office Coins % Out of Pocket Maximum* Indiv/Family Pharmacy RSHE1 00/00 00/00 Ded & Coins *Deductible plus Coinsurance Stoploss equals Out of Pocket Maximum 00/00 100% after cal year deductible 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. 12
13 13 HMO Blue Texas Plans
14 Health Plan # Office Visit In-Hospital ER Out of Pocket Maximum PDP RPlan09 $20 PCP/$20 Specialist 0 per admission $75 per visit $1500/00 PD10 $10/25/40 RPlan11 PCP/ Specialist $750 per admission $75 per visit 00/00 PD11 $15/30/45 RPlan12 PCP/ Specialist 0 per admission $75 per visit PD12 $20/35/50 RPlan13 $10 PCP/ Specialist $350 per admission per visit $1500/00 PD10 $10/25/40 RPlan14 $15 PCP/$35 Specialist 0 per admission $125 per visit $2000/00 PD11 $15/30/45 RPlan15 $20 PCP/ Specialist $600 per admission $150 per visit 00/00 PD11 $15/30/45 RPlan16 PCP/ Specialist 0 per admission $150 per visit PD12 $20/35/50 RPlan17 PCP/ Specialist $1250 per admission $150 per visit PD13 RPlan18 $35 PCP/ Specialist $1250 per admission $150 per visit 00/$8000 PD13 RPlan19 PCP/$60 Specialist $1500 per admission $150 per visit 00/$8000 PD13 RPlan99 per visit 0 per day/00 max $150 per visit 00/00 PD 99 $20/35/50 14
15 15 HMO Options
16 Option Description PD99* DM1 DM2 IM1 IM2 IM4 O2 IC SH IV $20/35/50 (MAC III) DME - No ment DME - 20% ment Inpatient Mental Health - Covered Same As Any Other Illness Inpatient Mental Health - 50% ment Inpatient Mental Health (If MHPAE applies) Same as hospital copay, no day limits Vision Exam Only - $10 copay every 12 months; lens exam - $20 every 12 months No Hardware Vision Services Eyeglass exam is $5 copay every 12 months; lens exam included in cost of lenses w/exam every 12 months. Standard frames $5 copay every 24 months and non-standard frames have higher copays Speech and Hearing Benefit (Not available with HMO Plan 99) Texas mandated offering In Vitro Fertilization Benefit (Not available with HMO Plan 99) Texas mandated offering Included SM1 Optional SMI SM2 Required if public entity *Does not include, in whole or in part, coverage for State Mandated prescription contraceptive drugs and devices and related drugs (Oral Contraceptives not excluded). Available with HMO Plan 99 only. 16
17 17 Consumer Choice Plans PPO: BlueChoice Network HMO: HMO Blue Texas Network
18 PPO Plan: Consumer Choice RL100 Plan does not include, in whole or in part, coverage for the following State Mandated health care benefits: treatment of Chemical Dependency, Prescription Contraceptive drugs and devices and related drugs (Oral Contraceptives not excluded), In-Vitro Fertilization, Serious Mental Illness (non-public entities only), Speech and Hearing, and Home Health Care. HMO Plan: Consumer Choice RPlan 99 Plan does not include, in whole or in part, coverage for the following State Mandated health care benefits: treatment of Chemical Dependency, Prescription Contraceptive drugs and devices and related drugs (Oral Contraceptives not excluded), In-Vitro Fertilization, Serious Mental Illness (non-public entities only) and Speech and Hearing. 18
19 HMO Prescription Drug Rider: Consumer Choice PD 99 Plan does not include, in whole or in part, coverage for the following State Mandated health care benefits: Prescription Contraceptive Drugs and devices and related drugs (Oral Contraceptives not excluded). PD 99 is the only Prescription Drug Option available for HMO Consumer Choice Plan
20 20 BlueCare Freedom Dental Plans
21 21 50%/0 Deluxe 100/80/50 0 /$ D821 50%/$2000 Deluxe 100/80/50 $2000 /$ D803 0%/$0 Deluxe 100/80/50 0 /$ D811 50%/0 Deluxe 100/80/50 $1500 /$ D822 50%/$1500 Deluxe 100/80/50 $2000 /$ D802 50%/$1500 Deluxe 100/80/50 $1500 /$ D801 50%/$1500 Value 100/80/50 $1500 /$ D702 50%/0 Value 100/80/50 $1500 /$ D701 0%/$0 Value 100/80/50 $1500 /$ D602 0%/$0 Value 100/80/50 0 /$ D601 0%/$0 Value 100/80/0 $750 /$75 2+ D501 Ortho %/ LifeMax Allocation of Services Benefit Level Annual Max Deductible Indiv/Family Enrollees Plan
22 Available Health Plan Options: Plan Type Description PPO One PPO or HSA plan. HMO One HMO Plan. Dual Option PPO Multiple Option Product (MOP) Triple Option Product Any two plans PPO or HSA Four Tier Rx Plans can be paired with another Four Tier plan or an HSA One PPO (excluding Four Tier Rx Plans) or HSA and an HMO plan. Three HSA plans are allowed. One of the following is required: HSA plan, RS32, RS33 or RS34. Only one HMO plan is allowed. Four Tier Rx Plans can only be offered with an HSA. 22
23 Available Dental Plan Options: Plan Type Description Dental Dual Option Dental Select one Dental plan depending on group size. Allowable combinations for group sizes 2-9: D501 and D601 D501 and D602 Allowable combinations for group sizes 10-50: 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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