Insurance Services

TSCRA BlueChoice Individual Benefits

Super Saver Plan

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FEATURES		Premium Plan - $500 Deductible with dental		Select Plan - $1,500 Deductible with dental
		In-Network	Out-of-Network	In-Network	Out-of-Network
Coinsurance		80%	60%	70%	50%
Annual Deductible		$500 Individual $1,500 Family	$1,000 Individual $3,000 Family	$1,500 Individual $4,500 Family	$3,000 Individual $9,000 Family
Annual Out-of-Pocket		$3,000 Individual $6,000 Family	$4,500 Individual $9,000 Family	$4,000 Individual $8,000 Family	$6,000 Individual $12,000 Family
Lifetime Maximum		$2,000,000		$2,000,000
Office Visit (PCP and Specialist)		$25 copay	60% after deductible	$30 consultation only	50% after deductible
Routine Preventive Care		$25 copay	60% after deductible	$30 copay	50% after deductible
Inpatient Hospital Care		80% after $250 Copay per Admission	60% after $500 Copay per Admission	70% after $250 Copay per Admission	50% after $500 Copay per Admission
Outpatient Hospital Care/Surgery		80% after deductible	60% after deductible	70% after deductible	50% after deductible
Emergency Care		80% after $150 copay for facility 80% after deductible for physician		70% after $200 copay for facility 70% after deductible for physician
Maternity		Included		Included
Pharmacy - Retail (30 day supply)		$10 Copay - Generic $40 Copay - Brand $60 Copay - Non-Preferred Brand		$200 Annual Deductible $3,000 Calendar Year Maximum $10 Copay - Generic $40 Copay - Brand $60 Copay - Non-Preferred Brand
Pharmacy - Mail (90 day supply)		3 X Retail		3 X Retail
Policy Includes $5,000 life insurance on primary insured with dependent life available.
Dental Plan Coverage		Preventative Care	Basic Care	Major Care	Max Year Benefit
		80% No deductible X-ray, Cleanings, Examinations	80% after $50 deductible per person Extractions, Fillings, Repair of Crowns, Dentures, etc...	50% after $50 deductible per person Crowns, Bridges, Crown Buildups, Oral Surgery, Treatment of Gum Disease, Root Canal Therapy, Bone Structure Support.	$1,500 per year per person for Preventive, Basic and Major Care
The above comparison is not the "Plan Summary Document." Please refer to the Master Benefit PlanDocument and Benefit booklet for limitations and exclusions. TSCRA's insurance plans are not guaranteedissue plans. Qualification for the plan is based on current and past medical history along with appropriaterelated information. The percent of payment refers to the allowable amount as determined by Blue Cross and Blue Shield of Texas.