51-150 market segment guidecontentz.mkt2527.com/lp/11207/123742/mmsegguide_1.1.14ext.pdf · 51-150...
TRANSCRIPT
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
BlueChoice® Network
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
BlueChoice® Network
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
BlueChoice® Network
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
RMH2 $3000/$6000 $6000/$12000 Ded & Coins 100%/70% $3000/$6000 100% after cal year
deductible
RMH3 $5000/$10000 $10000/$20000 Ded & Coins 100%/70% $5000/$10000 100% after cal year
deductible
RMH6 $3500/$7000 $7000/$14000 Ded & Coins 80%/60% $5000/$10000 80% after cal year
deductible
RMH7 $2500/$5000 $5000/$10000 Ded & Coins 80%/60% $5000/$10000 80% after cal year
deductible
RMH8 $4000/$8000 $8000/$16000 Ded & Coins 100%/70% $4000/$8000 100% after cal year
deductible
RMH9 $3500/$7000 $7000/$14000 Ded & Coins 100%/70% $3500/$7000 100% after cal year
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
RMH4 $1500/$3000 $3000/$6000 Ded & Coins 80%/60% $4500/$9000 80% after cal year
deductible
RMH5 $3000/$6000 $6000/$12000 Ded & Coins 100%/70% $3000/$6000 100% after cal year
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
RPlan 31 $25 PCP/$25 Specialist $750 per admission $75 per visit $2500/$5000 PD11 $15/30/45
RPlan 32 $30 PCP/$30 Specialist $1000 per admission $75 per visit $3000/$6000 PD12 $20/35/50
RPlan33 $10 PCP/$30 Specialist $350 per admission $100 per visit $1500/$3000 PD10 $10/25/40
RPlan34 $15 PCP/$35 Specialist $500 per admission $125 per visit $2000/$4000 PD11 $15/30/45
RPlan35 $20 PCP/$45 Specialist $600 per admission $150 per visit $2500/$5000 PD11 $15/30/45
RPlan36 $25 PCP/$45 Specialist $1000 per admission $150 per visit $3000/$6000 PD12 $20/35/50
RPlan37 $30 PCP/$50 Specialist $1250 per admission $150 per visit $3000/$6000 PD13 $20/40/60
RPlan38 $35 PCP/$55 Specialist $1250 per admission $150 per visit $4000/$8000 PD13 $20/40/60
RPlan39 $40 PCP/$60 Specialist $1500 per admission $150 per visit $4000/$8000 PD13 $20/40/60
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