Insurance Services
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Insurance
Services
|
Return to TSCRA Web Site |
TSCRA BlueChoice Individual Benefits
Super Saver Plan
| Type of Service | In-Network Benefits | Out-of-Network Benefits | Out-of-Area Benefits |
| Calendar Year Deductible | $500
Individual/ $1,500 Family |
$1,000
Individual/ $3,000 Family |
$400
Individual $1,200 Family |
| Hospital Admission Deductible | $100 | $200 | |
| Hospital Benefit Percentage | 80% after deductible | 60% after deductible | 80% |
| Calendar
Year Out-of-Pocket Maximum |
$3,000 per Individual | $4,500 per Individual | $3,000 per Individual |
| Lifetime Maximum | $2,000,000 | $2,000,000 | $2,000,000 |
| Doctor Visit | 100% after $25 Copay | 70% after deductible | 80% after deductible |
| Other Physician Services Maternity Care, Office & Outpatient Surgery, Inpatient Visits & Surgery | 80% after deductible | 60% after deductible | 80% after deductible |
| Other
Professional Services Diagnostic Lab, X-rays, Therapy, Durable Medical Equipment |
80% after deductible | 60% after deductible | 80% after deductible |
| Prescription Drug Program and Mail Order Prescriptions | $45
non-preferred $30 Preferred $10 generic |
$45
non-preferred $30 Preferred $10 generic |
$45
non-preferred $30 Preferred name $10 generic |
| Preventive
Care Routine Physical Exam, Well Baby Exam Office Services, Laboratory, X-rays, Immunizations |
100% after $25 Copay | 70% after deductible | $200 maximum
per 2-year period 80% deductible waived 80% deductible waived |
Dental-Plan Coverage
| Preventive Care | Basic Care | Major Care | Maximum Calendar 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 Plan Document and
Benefit booklet for limitations and exclusions. TSCRA's SuperSaver insurance
plan is not a guaranteed issue plan. Qualification for the plan is based on
current and past medical history along with appropriate related information. The
percent of payment refers to the allowable amount as determined by Blue Cross
and Blue Shield of Texas.
Call: 1-800-252-2849