51-150 market segment guidecontentz.mkt2527.com/lp/11207/123742/mmsegguide_1.1.14ext.pdf · 51-150...

51-150 Market Segment Guide Effective 1/1/14

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

an Independent Licensee of the Blue Cross and Blue Shield Association.

1

PPO Plans

BlueChoice® Network

2

3

Health Plan #

Ded

Ind/Fam

Office

Copay

Coins %

In/Out

OPX

Ind/Fam Pharmacy

RM01 $250/$750 $15 90%/70% $1250/$3750 $15/30/45

RM02 $500/$1500 $15 90%/70% $2500/$7500 $15/30/45

RM03 $500/$1500 $15 80%/60% $2500/$7500 $15/30/45

RM04 $500/$1500 $20 80%/60% $3000/$9000 $20/35/50

RM05 $750/$2250 $20 80%/60% $3750/$11250 $15/30/45

RM06 $1000/$3000 $20 100%/70% $1500/$4500 $15/30/45

RM07 $1000/$3000 $20 80%/60% $350010500 $15/30/45

RM08 $1000/$3000 $25 90%/70% $4000/$12000 $15/30/45

RM09 $1000/$3000 $25 80%/60% $4000/$12000 $20/35/50

RM10 $1000/$3000 $25 75%/50% $5000/$12700 $20/40/60

RM11 $1000/$3000 $30 80%/60% $5000/$12700 $20/35/50

RM14 $1500/$4500 $20 80%/60% $4500/$12700 $15/30/45

RM15 $1500/$4500 $25 75%/50% $4500/$12700 $15/40/55

RM16 $1500/$4500 $30 80%/60% $4500/$12700 $20/35/50

RM17 $1500/$4500 $30 75%/50% $5500/$12700 $20/40/60

4

Health Plan

# Ded Ind/Fam

Office

Copay

Coins %

In/Out

OPX

Ind/Fam Pharmacy

RM18 $2000/$6000 $20 80%/60% $5000/$12700 $15/40/55

RM19 $2000/$6000 $25 75%/50% $5000/$12700 $15/40/55

RM20 $2000/$6000 $30 75%/50% $6000/$12700 $20/40/60

RM22 $2500/$7500 $25 80%/60% $5500/$12700 $10/40/60

RM23 $2500/$7500 $25 70%/50% $5500/$12700 $20/40/60

RM24 $2500/$7500 $30 70%/50% $6350/$12700 $20/40/60

RM25 $3000/$9000 $30 100%/70% $3500/$10500 $10/40/60

RM26 $3000/$9000 $40 70%/50% $6350/$12700 $20/40/60

RM28 $4000/$8000 $40 70%/50% $6350/$12700 $20/40/60

RM29 $4000/$8000 $40 50%/50% $6350/$12700 $20/40/60

RM30 $5000/$10000 $30 100%/70% $5500/$11500 $10/40/60

RM31 $5000/$10000 $40 80%/60% $6350/$12700 $20/40/60

RM32 $5000/$10000 $40 70%/50% $6350/$12700 $20/40/60

5

Copay applies to the Physician Office Visit Only and Lab & X-Ray paid after coinsurance

Copay applies to the Physician Office Visit Only and Lab & X-Ray paid after deductible and coinsurance

Health Plan # Ded

Ind/Fam

Office

Copay

Coins %

In/Out

OPX

Ind/Fam

Pharmacy

RM36 $2000/$6000 $30 100%/80% $2500/$7500 $20/35/50

RM37 $4000/$12000 $30 100%/70% $4500/$12700 $20/40/60

RM38 $2500/$7500 $25 100%/70% $3000/$9000 $15/30/45

RM40 $6350/$12700 $25 100%/70% $6350/$12700 $15/40/60

RM42 $1000/$3000 $20 80%/60% $4000/$12000 $15/30/45

RM43 $1000/$3000 $30 80%/60% $4000/$12000 $25/35/50

RM44 $2000/$6000 $25 90%/70% $5000/$12700 $15/30/45

RM45 $3000/$9000 $45 70%/50% $6350/$12700 $20/40/60

RMB1

$1000/$3000 $20 80%/60% $4000/$12000 $15/40/55

RMB2

$2500/$7500 $30 80%/60% $6350/$12700 $20/40/60

RMB3

$3000/$9000 $30 80%/60% $6000/$12700 $10/40/60

RMBA4

$5000/$10000 $40 70%/50% $6350/$12700 $20/40/60

BlueChoice® PPO

Four Tier Rx Copay Plans


6

Health Plan

#

Ded

Ind/Fam Office Copay

Coins %

In/Out

OPX

Ind/Fam

Pharmacy*

RMF1 $3000/$9000 $30 100%/70% $3500/$10500 $8/35/75/150

RMF2 $1000/$3000 $20 100%/70% $1500/$4500 $8/35/75/150

RMF3 $2000/$6000 $20 80%/60% $5000/$12700 $8/35/75/150

RMF4 $3000/$9000 $40 70%/50% $6350/$12700 $8/35/75/150

RMF5 $1000/$3000 $25 80%/60% $4000/$12000 $8/35/75/150

RMF7 $1500/$4500 $30+ 80%/60% $4500/$12700 $10/35/75/150

RMF8 $2000/$6000 $20+ 80%/60% $5000/$12700 $10/35/75/150

7

*Preferred Drug List 1 applies to all Middle Market Plans except Four Tier Rx Copay Plans which

are subject to Preferred Drug List 2.

+Copay applies to the physician office visit only.

Enhanced Rx Plans


8

•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 Copayment Amount

•If “Brand Medically Necessary” IS indicated on the prescription, the member will pay the Preferred or Non-Preferred

Brand Name Copayment

9

Health

Plan #

Ded Ind/Fam

Office

Copay

Coins %

In/Out

OPX

Ind/Fam

Pharmacy

RME01 $500/$1500 $15 90%/70% $2500/$7500 $15/30/45

RME02 $500/$1500 $20 80%/60% $3000/$9000 $20/35/50

RME03 $750/$2250 $20 80%/60% $3750/$11250 $15/30/45

RME04 $1000/$3000 $20 100%/70% $1500/$4500 $15/30/45

RME05 $1000/$3000 $20 80%/60% $3500/$10500 $15/30/45

RME06 $1000/$3000 $25 80%/60% $4000/$12000 $20/35/50

RME07 $1000/$3000 $30 80%/60% $5000/$12700 $20/35/50

RME08 $1500/$4500 $30 80%/60% $4500/$12700 $20/35/50

RME09 $2000/$6000 $30 100%/80% $2500/$7500 $20/35/50

RME10 $3000/$9000 $30 100%/70% $3500/$10500 $10/40/60

RME11 $3000/$9000 $40 70%/50% $6350/$12700 $20/40/60

Health Savings Account* Plans


10

*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.

Health

Plan #

Ded In/Out

Individual

Ded In/Out

Family

Office Copay Coins %

In/Out

Out of Pocket

Maximum*

Indiv/Family

Pharmacy

RMH1 $2500/$5000 $5000/$10000 Ded & Coins 100%/70% $2500/$5000 100% after cal year

deductible


deductible


deductible


deductible


deductible


deductible


deductible

*Deductible plus Coinsurance Stoploss equals Out of Pocket Maximum

11

Embedded Deductible Plans†

†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.

Health

Plan #

Ded In/Out

Individual

Ded In/Out

Family

Office Copay Coins %

In/Out

Out of Pocket

Maximum*

Indiv/Family

Pharmacy


deductible


deductible

*Deductible plus Coinsurance Stoploss equals Out of Pocket Maximum

12

Aggregate Deductible Plans†

†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.

BlueEdge™ HCA

13

BlueEdge HCA (Non-Integrated Drug Plans)

Health

Plan #

Office

Copay

HCA Funding*

Indiv/Family

Ded

Indiv/Family

Coins %

In/Out

OPX

Indiv/Family Pharmacy

R9104 N/A $500/$1000 $2000/$4000 80%/60% $4500/$9000 $20/40/60

*Healthcare account is funded by the employer

14

BlueEdge HCA (Integrated Drug Plans)

*Healthcare account is funded by the employer

Health

Plan #

Office

Copay

HCA Funding*

Indiv/Family

Ded

Indiv/Family

Coins %

In/Out

OPX

Indiv/Family Pharmacy

R9203R N/A $750/$1500 $1500/$3000 80%/60% $3750/$7500 80% after cal yr ded

R9502R N/A $500/$1000 $5000/$10000 100%/70% $5500/$11000 100% after cal yr ded

15

HMO Blue® Texas Plans

16

17

Health

Plan # Office Visit Copay In-Hospital Copay ER Copay

Out of Pocket

Maximum PDP Copay

RPlan 29 $20 PCP/$20 Specialist $500 per admission $75 per visit $1500/$3000 PD10 $10/25/40



RPlan33 $10 PCP/$30 Specialist $350 per admission $100 per visit $1500/$3000 PD10 $10/25/40







HMO Options

18

19

Option Description

DM3 DME - No Copayment

DM4 DME - 20% Copayment

IM4 Inpatient Mental Health - 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/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 frames $5 copay every 24 months and non-standard 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 frames $15 copay every 24 months and non-standard frames have higher copays.

SH0 Speech and Hearing Option

IV0 In Vitro Fertilization Option

BlueCare® Freedom Dental Plans

20

21

Plan Deductible

Indiv/Family Annual Max Benefit Level

Allocation

of Services

Ortho %/

LifeMax

D501 $25/$75 $750 100/80/0 Value 0%/$0

D601 $50/$150 $1000 100/80/50 Value 0%/$0

D602 $50/$150 $1500 100/80/50 Value 0%/$0

D701 $50/$150 $1500 100/80/50 Value 50%/$1000

D702 $50/$150 $1500 100/80/50 Value 50%/$1500

D801 $50/$150 $1500 100/80/50 Deluxe 50%/$1500

D802 $50/$150 $2000 100/80/50 Deluxe 50%/$1500

D803 $50/$150 $2000 100/80/50 Deluxe 50%/$2000

D811 $50/$150 $1000 100/80/50 Deluxe 0%/$0

D821 $50/$150 $1000 100/80/50 Deluxe 50%/$1000

D822 $50/$150 $1500 100/80/50 Deluxe 50%/$1000

22

Available Health Plan Options:

Plan Type Description

PPO One PPO, HSA or HCA plan.

Dual Option PPO Any two plans PPO, HSA or HCA

Four Tier Rx Plans can be paired with

another Four Tier plan or an HSA.

Dual Option PPO

(Enhanced Rx)

Any two Enhanced Rx PPO plans.

Enhanced Rx plans can be paired with an

HSA plan.

Multiple Option Product (MOP) One PPO, HSA or HCA plan (excluding

Enhanced Rx and Four Tier Rx Plans) and

an HMO plan.

Triple Option Product ●Three HSA and/or HCA plans are

allowed.

●One of the following is required: HSA,

HCA or RM32.

●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.

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

51-150 market segment guidecontentz.mkt2527.com/lp/11207/123742/mmsegguide_1.1.14ext.pdf · 51-150...

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