Page 17 - 2021 Summer Enrollment

Medical Benefits
Service
HealthSelect of Texas® and HealthSelectSM Out-of-State
In-Network
HealthSelect of Texas and HealthSelect Out-of-State
Out-of-Network
Consumer Directed HealthSelectSM High-deductible Health Plan
In-Network
Consumer Directed HealthSelect High-deductible Health Plan
Out-of-Network
Allergy treatment
Covered at 100% if administered in a physician’s office; 20% coinsurance in any other outpatient location
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Ambulance services
(for emergencies)
20% coinsurance
20% coinsurance; annual deductible does not apply
20% coinsurance after annual deductible is met
20% coinsurance after annual in-network deductible is met
Bariatric surgery2
• Deductible: $5,000
• Coinsurance: 20%
• Lifetime max: $13,000
Not covered
Not covered
Not covered
Chiropractic care
• Without office visit: 20% coinsurance
• With office visit: $40 copay plus 20% coninsurance
• Maximum benefits of $75 per visit and maximum of 30 visits per calendar year
40% coinsurance after annual deductible is met.
Maximum benefits of $75 per visit and maximum of 30 visits per calendar year
20% coinsurance after annual deductible is met.
Maximum benefits of $75 per visit and maximum of 30 visits per calendar year
40% coinsurance after annual deductible is met.
Maximum benefits of $75 per visit and maximum of 30 visits per calendar year
Diabetes equipment2
20% coinsurance;
see page 20 for details.
40% coinsurance after annual deductible is met;
see page 20 for details.
20% coinsurance after annual deductible is met;
see page 20 for details.
40% coinsurance after annual deductible is met;
see page 20 for details.
Diabetes supplies
See page 20 for details.
Diagnostic X-rays and lab tests
Durable medical equipment2
20% coinsurance 20% coinsurance
40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Diagnostic mammography
Covered at 100%
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
Facility-based providers (radiologists, pathologists and labs, anesthesiologists, emergency room physicians etc.)
20% coinsurance
Emergencies: 20% coinsurance; annual deductible does not apply.
Non-emergencies: 40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
Emergencies: 20% coinsurance after annual in-network deductible is met.
Non-emergencies: 40% coinsurance after annual out-of- network deductible is met.
Facility emergency care (non-FSER) and hospital-affiliated freestanding emergency departments
$150 copay plus 20% coinsurance
(If admitted, copay will apply to hospital copay.)
Emergencies: $150 copay plus 20% coinsurance (If admitted, copay will apply to hospital copay.) Annual deductible does not apply.
Non-emergencies: $150 copay plus 40% coinsurance after annual out-of-network deductible is met.
20% coinsurance after annual deductible is met
Emergencies: 20% coinsurance after annual in-network deductible is met.
Non-emergencies: 40% coinsurance after annual out-of- network deductible is met.
Freestanding emergency room facility
$150 copay plus 20% coinsurance
Emergencies: $300 copay plus 20% coinsurance; annual deductible does not apply.
Non-emergencies: $300 copay plus 40% coinsurance after annual out-of-network deductible is met.
20% coinsurance after annual deductible is met
Emergencies: 20% coinsurance after annual in-network deductible is met.
Non-emergencies: 40% coinsurance after annual out-of- network deductible is met.
Habilitation and rehabilitation services - outpatient therapy (including physical therapy, occupational therapy and speech therapy)
20% coinsurance
40% coinsurance after annual deductible is met
20% coinsurance after annual deductible is met
40% coinsurance after annual deductible is met
2Preauthorization may be required.
17 Call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039 (TTY:711), Monday - Friday 7 a.m. - 7 p.m. and Saturday 7 a.m. - 3 p.m. CT Compare Health Plans