The chart below gives a summary of the 2017 medical coverage provided by Blue Cross and Blue Shield of Texas and Kaiser. All covered services are subject to medical necessity as determined by the Plan. Please be aware that all out-of-network services are subject to Reasonable and Customary (R&C) limitations.
SOB HSA 4000 SOB PPO1 SOB PPO2
| PPO 750 | ||
| IN-NETWORK | OUT-OF-NETWORK | |
| CALENDAR YEAR DEDUCTIBLE | ||
| Individual | $750 | $5,000 |
| Family | $1,500 | $10,000 |
| Coinsurance(Plan Pays) | 80%* | 50%* |
| CALENDAR YEAR OUT-OF-POCKET MAXIMUM (MAXIMUM INCLUDES DEDUCTIBLE) | ||
| Individual | $5,000 | $10,000 |
| Family | $10,000 | $20,000 |
| Lifetime Maximum | Unlimited | |
| COPAYS/COINSURANCE | ||
| Outpatient Services | 20%* | 50%* |
| Specialist Services | 20%* | 50%* |
| Preventive Care | No deductible / copay / coinsurance | No deductible / copay / coinsurance |
| Urgent Care | 20%* | 50%* |
| Emergency Room | 20%* | 20%* |
*After Deductible
| PPO 2500 | ||
| IN-NETWORK | OUT-OF-NETWORK | |
| CALENDAR YEAR DEDUCTIBLE | ||
| Individual | $2,500 | $5,000 |
| Family | $5,000 | $10,000 |
| Coinsurance(Plan Pays) | 70%* | 50%* |
| CALENDAR YEAR OUT-OF-POCKET MAXIMUM (MAXIMUM INCLUDES DEDUCTIBLE) | ||
| Individual | $5,000 | $10,000 |
| Family | $10,000 | $20,000 |
| Lifetime Maximum | Unlimited | |
| COPAYS/COINSURANCE | ||
| Outpatient Services | 30%* | 50%* |
| Specialist Services | 30%* | 50%* |
| Preventive Care | No deductible / copay / coinsurance | No deductible / copay / coinsurance |
| Urgent Care | 30%* | 50%* |
| Emergency Room | 30%* | 20%* |
*After Deductible
| HSA | ||
| IN-NETWORK | OUT-OF-NETWORK | |
| CALENDAR YEAR DEDUCTIBLE | ||
| Individual | $4,000 | $5,000 |
| Family | $8,000 | $10,000 |
| Coinsurance(Plan Pays) | 100%* | 50%* |
| CALENDAR YEAR OUT-OF-POCKET MAXIMUM (MAXIMUM INCLUDES DEDUCTIBLE) | ||
| Individual | $4,000 | $10,000 |
| Family | $8,000 | $20,000 |
| Lifetime Maximum | Unlimited | |
| COPAYS/COINSURANCE | ||
| Outpatient Services | 0%* | 50%* |
| Specialist Services | 0%* | 50%* |
| Preventive Care | No deductible / copay / coinsurance | No deductible / copay / coinsurance |
| Urgent Care | 0%* | 50%* |
| Emergency Room | 0%* | 0%* |
*After Deductible
| KAISER** | |
| IN-NETWORK | |
| CALENDAR YEAR DEDUCTIBLE | |
| Individual | None |
| Family | None |
| Coinsurance (Plan Pays) | None |
| CALENDAR YEAR OUT-OF-POCKET MAXIMUM (MAXIMUM INCLUDES DEDUCTIBLE) | |
| Individual | $1,500 |
| Family | $3,000 |
| Lifetime Maximum | Unlimited |
| COPAYS/COINSURANCE | |
| Outpatient Services | $20 copay |
| Specialist Services | $20 copay |
| Preventive Care | No deductible / copay / coinsurance |
| Urgent Care | $20 copay |
| Emergency Room | $20 copay |
*After Deductible