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TSCRA BlueChoice Individual Benefits

Super Saver Plan

Click Here for the enrollment form!

 
   
BCBS
BCBS
   
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.

For more informatrion, call: 1-800-252-2849



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