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PPO 750 PPO 750

ALVIN ISD 2010-2011 Blue Cross Blue Shield of Texas

Plan pays for

Plan pays for

This is a partial list of benefits.

services from

services from

See separate Benefit Summary

PARTICIPATING

NONPARTICIPATING

for each plan for more specific

providers

providers

details Up-front Benefit Allowance Annual Per Member Benefit

N/A

N/A

Annual routine physical exam

100% after

70% after deductible

and routine child care

$25/$40 copay

-

Routine mammogram/papsmear

100%

70% after deductible

-

Routine lab and X-ray

-

Vision exam

N/A

N/A

-

Office Visits and prenatal care

100% after

70% after deductible

Allowance Preventative Care -

Physician Services $25/$40 copay -

Allergy injections

100% after $5 copay

70% after deductible

-

Inpatient/outpatient services

80% after deductible

50% after deductible

-

Allergy serum

-

Inpatient Care

80% after deductible

50% after deductible

-

Per Admission

$100 per day 5 max

$500

-

Preauthorization Penalty

None

$250

Outpatient Surgery

100% after $100 copay

70% after deductible

Hospital Services

-

after deductible -

Outpatient nonsurgical care

80% after deductible

50% after deductible

100% after $100 copay

100% after deductible

(include diagnostic lab & X-ray) -

Emergency Room

after deductible -

E. R. Physician Charges

80% after deductible

80% after deductible

-

Physical Therapy

80% after deductible

50% after deductible

100% after

50% after

Other Medical Services Speech & Hearing Prescription Drugs -

Rx 4 coverage


-

Mail Order (3 mos. supply)

$10/$25/$50/$100

$10/$25/$50/$100

One times the retail

One times the retail

copay

copay

Annual Deductibles (per plan year) -

Individual

$750*

-

Family

$2,000 Reduce to $1,500

$4,500

-

Individual

$2,000

$4,000

-

Family

$6,000

$12,000

Reduce to $500

$1,500

Annual Out of Pocket Amt.

Lifetime Maximum

$5,000,000

* Incentive: Participate in 3 programs and have your deductible reduced to $500


PPO 1500 Without RX Card

PPO 1500 without Rx Card

ALVIN ISD 20102011 Blue Cross Blue Shield of Texas

Plan pays for

Plan pays for

This is a partial list of benefits.

services from

services from

See separate Benefit Summary

PARTICIPATING

NONPARTICIPATING

for each plan for more specific

providers

providers

details Up-front Benefit Allowance Annual Per Member Benefit

$500

N/A

100% after copay $30/$45,until $500 allowance is exhausted

70% after deductible

80% after deductible

50% after deductible

Allowance Preventative Care

-

Annual routine physical exam and routine child care

-

Routine mammogram/papsmear

-

Routine lab and X-ray

-

Vision exam

N/A

N/A

-

Office Visits and prenatal care

100% after copay $30/$45,until $500 allowance is exhausted

70% after deductible

-

Allergy injections

100% after $5 copay

70% after deductible

-

Inpatient/outpatient services

80% after deductible

50% after deductible

-

Allergy serum

-

Inpatient Care

100% after deductible

70% after deductible

-

Per Admission

$100 per day 5 max

$500

-

Preauthorization Penalty

None

$250

Outpatient Surgery

100% after $100 copay

70% after deductible

Physician Services

Hospital Services

-

after deductible -

Outpatient nonsurgical care (include diagnostic lab & Xray)

80% after deductible

50% after deductible

-

Emergency Room

100% after $100 copay

100% after $100 copay


after deductible

after deductible

-

E. R. Physician Charges

80% after deductible

80% after deductible

-

Physical Therapy

80% after deductible

50% after deductible

80% after deductible

50% after deductible

Other Medical Services Speech & Hearing Prescription Drugs -

Rx 4 coverage

Must satisfy deductible first -

Mail Order (3 mos. supply)

80% after deductible

50% after deductible

-

Individual

$1,500

$3,000

-

Family

$4,500

$9,000

-

Individual

$3,000

$6,000

-

Family

$9,000

$18,000

Annual Deductibles (per plan year)

Annual Out of Pocket Amt.

Lifetime Maximum

$5,000,000


PPO 1500 With RX Card PPO 1500 with Rx Card

ALVIN ISD 20102011 Blue Cross Blue Shield of Texas

Plan pays for

Plan pays for

This is a partial list of benefits.

services from

services from

See separate Benefit Summary

PARTICIPATING

NONPARTICIPATING

for each plan for more specific

providers

providers

details Up-front Benefit Allowance Annual Per Member Benefit

$500

N/A

100% after copay $30/$45,until $500 allowance is exhausted

70% after deductible

80% after deductible

50% after deductible

Allowance Preventative Care

-

Annual routine physical exam and routine child care

-

Routine mammogram/papsmear

-

Routine lab and X-ray

-

Vision exam

N/A

N/A

-

Office Visits and prenatal care

100% after copay $30/$45,until $500 allowance is exhausted

70% after deductible

-

Allergy injections

100% after $5 copay

70% after deductible

-

Inpatient/outpatient services

80% after deductible

50% after deductible

-

Allergy serum

-

Inpatient Care

100% after deductible

70% after deductible

-

Per Admission

$100 per day 5 max

$500

-

Preauthorization Penalty

None

$250

Outpatient Surgery

100% after $100 copay

70% after deductible

Physician Services

Hospital Services

-

after deductible -

Outpatient nonsurgical care (include diagnostic lab & Xray)

80% after deductible

50% after deductible

-

Emergency Room

100% after $100 copay

100% after $100 copay

after deductible

after deductible

80% after deductible

80% after deductible

-

E. R. Physician Charges


Other Medical Services -

Physical Therapy

80% after deductible

50% after deductible

100% after

50% after

$10/$25/$50/$100

$10/$25/$50/$100

One times the retail

One times the retail

copay

copay

Speech & Hearing Prescription Drugs -

-

Rx 4 coverage

Mail Order (3 mos. supply)

Annual Deductibles (per plan year) -

Individual

$1,500

$3,000

-

Family

$4,500

$9,000

-

Individual

$3,000

$6,000

-

Family

$9,000

$18,000

Annual Out of Pocket Amt.

Lifetime Maximum

$5,000,000


PPO 750 PPO 750

ALVIN ISD 2010-2011 Blue Cross Blue Shield of Texas

Plan pays for

Plan pays for

This is a partial list of benefits.

services from

services from

See separate Benefit Summary

PARTICIPATING

NONPARTICIPATING

for each plan for more specific

providers

providers

details Up-front Benefit Allowance Annual Per Member Benefit

N/A

N/A

Annual routine physical exam

100% after

70% after deductible

and routine child care

$25/$40 copay

-

Routine mammogram/papsmear

100%

70% after deductible

-

Routine lab and X-ray

-

Vision exam

N/A

N/A

-

Office Visits and prenatal care

100% after

70% after deductible

Allowance Preventative Care -

Physician Services $25/$40 copay -

Allergy injections

100% after $5 copay

70% after deductible

-

Inpatient/outpatient services

80% after deductible

50% after deductible

-

Allergy serum

-

Inpatient Care

80% after deductible

50% after deductible

-

Per Admission

$100 per day 5 max

$500

-

Preauthorization Penalty

None

$250

Outpatient Surgery

100% after $100 copay

70% after deductible

Hospital Services

-

after deductible -

Outpatient nonsurgical care

80% after deductible

50% after deductible

100% after $100 copay

100% after deductible

(include diagnostic lab & X-ray) -

Emergency Room

after deductible -

E. R. Physician Charges

80% after deductible

80% after deductible

-

Physical Therapy

80% after deductible

50% after deductible

100% after

50% after

Other Medical Services Speech & Hearing Prescription Drugs -

Rx 4 coverage


-

Mail Order (3 mos. supply)

$10/$25/$50/$100

$10/$25/$50/$100

One times the retail

One times the retail

copay

copay

Annual Deductibles (per plan year) -

Individual

$750*

-

Family

$2,000 Reduce to $1,500

$4,500

-

Individual

$2,000

$4,000

-

Family

$6,000

$12,000

Reduce to $500

$1,500

Annual Out of Pocket Amt.

Lifetime Maximum

$5,000,000

* Incentive: Participate in 3 programs and have your deductible reduced to $500

Alvin 2010-2011 Medical  

Alvin Medical Plans Review

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