|
Health plan features at-a-glance |
Plan feature |
What you pay |
|
HMO |
PPO
in-network |
PPO
Out-of-network |
Deductible (Individual/Family) |
N/A |
$200 / $600 |
$400 / $1,200 |
PCP office visit copayment |
$20 |
$30 |
40% |
Specialist office visit copayment |
$45 |
$50 |
40% |
Routine physical copayment |
$0 |
$0 |
40% |
Well woman/man exam |
$0 |
$0 |
40% |
Inpatient admission copayment/coinsurance |
$500 |
$500 + 20% |
$1000 + 20% |
Emergency room |
$150 |
$150 + 20% |
$150 + 20% |
Ambulance |
$100 |
20% |
20% |
Outpatient surgery |
$200 |
20% |
40% |
Annual maximum copayment/coinsurance |
Individual |
$1,500 |
$3,000 |
$5,000 |
Family |
$3,000 |
$6,000 |
$10,000 |
Prescriptions participating pharmacy copayment* |
Retail pharmacy
(30-day supply) |
Generic |
$10 |
$10 |
$10 |
Preferred brand |
$30 |
$30 |
$30 |
Non-preferred brand |
$45 |
$45 |
$45 |
Mail-order pharmacy
(90-day supply) |
Generic |
$20 |
$20 |
$20 |
Preferred brand |
$60 |
$60 |
$60 |
Non-preferred brand |
$90 |
$90 |
$90 |
*Generics are mandatory if available.
| Doctors in the HMO and PPO |
Physician group |
HMO |
PPO |
Baylor |
X* |
X |
CardioVascular Care Providers, Inc. |
X*** |
X |
Independent Physicians, if listed |
X |
|
Inpatient Consultants of Texas |
|
X |
Kelsey-Seybold Clinics |
X |
X**** |
MD Anderson Cancer Center |
X*** |
X |
Medical Clinic of Houston |
|
X |
Memorial Hermann Healthnet Network Providers |
X** |
X |
Northwest Diagnostic Clinic |
X |
X |
OB/Gyn Associates |
|
X |
HMOBlue TX Limited Provider Network |
X |
X** |
Renaissance |
X |
X** |
Sadler Clinic |
X |
X |
UT Physicians |
|
X |
UTMB-Galveston |
|
X |
* Pediatricians/specialty care providers participating in the HMO network.
** Physicians may be available through independent contracts instead of through the IPA.
***Available through referral only.
****Kelsey-Seybold no longer provides services to Medicare-covered PPO members. See page 10 for more information.
Service Areas
The map below shows the broad coverage of the service area for HMO and PPO plans. The HMO includes more than 200 counties in Texas and the PPO includes every state, plus Puerto Rico. Your ID card is accepted by additional doctors and hospitals and a larger retail pharmacy network.
HMO
The HMO service area is as big as the state of Texas, except for these 34 counties — Archer, Bandera, Baylor, Clay, Coryell, DeWitt, Dimmit, Duval, Edwards, Falls, Foard, Frio, Gillespie, Goliad, Hamilton, Hardeman, Jim Hogg, Kerr, Kinney, Knox, LaSalle, Lampasas, Limestone, Live Oak, Llano, McMullen, Maverick, Real, Uvalde, Webb, Wichita, Wilbarger, Zapata, Zavala.
PPO
The BlueChoice PPO network is as big as America itself. That means employees and retirees under the plan can find contracted providers in every state, plus Puerto Rico.
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