Call toll-free (800) 252-8039 Monday-Friday 7 a.m. - 7 p.m ......2019 Medical Benefits Guide 1 Call toll-free (800) 252-8039 Monday-Friday 7 a.m. - 7 p.m. central time (CT) and Saturday

2019 Medical Benefits Guide 1

Call toll-free (800) 252-8039 Monday-Friday 7 a.m. - 7 p.m. central time (CT) and Saturday 7 a.m. - 3 p.m. CT

2019 MEDICAL BENEFITS GUIDESeptember 1, 2018 - August 31, 2019

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TABLE OF CONTENTS

4 Important Information 5 Don’t forget your ID card! 6 Resources for You 7 Stay Connected 8 Selecting a Primary Care Physician 9 Mental Health and Wellbeing 10 Options for Care 11 Virtual Visits 12 Sample Explanation of Benefits 14 Weight Management Program 15 Wellness Resources

Plan Information 16 HealthSelect of Texas 18 HealthSelect Out-of-State 20 Consumer Directed HealthSelect 22 HealthSelect Secondary 24 Health Plans Comparison Chart


We’re proud to be serving you.Health care is more than just knowing where to go when you get sick. It’s also about knowing how to stay well. In this medical benefits guide, you will find information about your medical benefits, health and wellness programs, resources available to you and incentive programs. We are here to help you every step of the way.

HealthSelectSM of Texas and Consumer Directed HealthSelectSM are managed by the Employees Retirement System of Texas (ERS). ERS sets plan benefits and pays claims. Blue Cross and Blue Shield of Texas (BCBSTX) manages the provider network, processes claims and provides customer service.

The 2019 health plan year begins on September 1, 2018 and runs through

August 31, 2019.


• If you have questions about your medical benefits, where to get care or your claims, call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday–Friday 7 a.m. - 7 p.m. CT and Saturday 7 a.m. - 3 p.m. CT.

• The HealthSelect network includes more than 50,000 doctors and other providers. To receive the highest level of benefits and help you keep your health care costs down, be sure your providers are in your plan’s network.

• To find a network provider (doctor, hospital, lab, medical professional, etc.), visit www.healthselectoftexas.com and click “Find a Doctor/Hospital” or call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday–Friday 7 a.m. - 7 p.m. CT and Saturday 7 a.m. - 3 p.m. CT.

• If you are enrolled in HealthSelect of Texas, you must obtain referrals from your primary care physician (PCP) before seeing specialists for care.

• BCBSTX must approve certain covered health services before you receive them. This is called a prior authorization. Find more details about referrals and prior authorizations at www.healthselectoftexas.com. Go to the “Medical Benefits” tab, then “Referrals and Prior Authorizations.”

• If you are enrolled in HealthSelect of Texas, HealthSelect Out-of-State, or HealthSelect Secondary, virtual visits are available at no cost to you. Consumer Directed HealthSelect participants will be required to meet their annual deductible before visits are covered, subject to coinsurance after the deductible is met.

• Weight management programs Naturally Slim® and Real Appeal® are available to eligible HealthSelect participants at no cost.1

• The Well onTarget® web portal provides a wealth of resources to support your health and wellness through a range of interactive, educational features.

• For more information about your prescription drug coverage, visit www.healthselectoftexas.com and click “Prescription Drug Benefits.”

Look for these icons throughout this brochure

1 See eligibility requirements on page 14.

Activities that will earn you Blue Points®

Tips on maximizing your benefits

Tips for cost savings

IMPORTANT INFORMATION


Don’t forget your ID CardAfter you enroll in a HealthSelect plan, you will receive your new Medical ID card in the mail in 7-10 business days.

Medical ID cards are not auto-generated annually. They are only mailed to new participants, currently enrolled participants changing plans or who have name changes and participants in HealthSelect of Texas who select or change primary care physicians on file with BCBSTX.

You will receive a separate ID Card for pharmacy benefits from your prescription drug benefits plan administrator. You need to use this ID card when you pay for prescriptions at the pharmacy. Go to www.healthselectoftexas.com to access information about your prescription drug benefits.

DON’T FORGET YOUR ID CARD!

HealthSelect Medical ID Card Samples

Note: On most medical ID cards you will see HME, which indicates that you are in the HealthSelect network. It does not mean you are in an HMO.


RESOURCES FOR YOU

BCBSTX Personal Health AssistantsPersonal Health Assistants are here to help you understand and use your health plan benefits. Call them to: • Answer questions about benefits • Assist with prior authorizations and referrals • Provide information about programs and benefits

available to you • Help you locate an in-network provider • Explain health care costs and options for care • Provide you with cost estimates for services • Schedule or cancel doctor’s appointments • Help you use self-service tools • Connect you to other resources

1 For medical emergencies, call 911. 24/7 Nurseline is not a substitute for a doctor’s care. Talk to your doctor about any health questions or concerns.2 Mental health benefits for HealthSelect Out-of-State participants, HealthSelectSM Secondary participants and Consumer Directed HealthSelect participants who live or work outside the State of Texas are managed by BCBSTX.

Get answers day or night with 24/7 NurselineSpeak with a registered nurse toll-free at (800) 581-0368. If you’re not sure where to go for care, or you just have a question, calling the 24/7 Nurseline may be your answer. Call any time, any day of the year.1

24/7 Mental Health Support HotlineYour medical plan offers mental health benefits to support your emotional and psychological well-being. Call (800) 442-4093 to talk with a counselor about mental health or substance use issues. Mental health benefits for HealthSelect of Texas and Consumer Directed HealthSelect participants are managed by Magellan Healthcare, which means you may be transferred to Magellan for additional information about your mental health benefits.2

Care Management CliniciansBCBSTX clinicians are available to help you achieve your health goals. They can provide support, point you to local resources, coordinate with your physicians and answer your questions to help empower you to properly manage your health condition.

When you engage with our clinicians, you have a dedicated resource providing support to you and your family.

Whether you have an upcoming surgery and have questions, recently had a surgery and need follow up support, or if you are managing a condition or are recently diagnosed, a BCBSTX clinician can support you.

If you have questions about conditions such as asthma, cancer, COPD, diabetes or cardiac conditions, contact BCBSTX toll-free at (800) 252-8039 and ask to speak with a clinician.

Call a BCBSTX Personal Health Assistant toll-free (800) 252-8039 Monday–Friday 7 a.m. - 7 p.m. CT and Saturday 7 a.m. - 3 p.m. CT


STAY CONNECTED

HealthSelect websiteThis website is dedicated to HealthSelect plan participants and has the most up-to-date information about your health plan benefits, value-added programs, resources and tools. Using the HealthSelect website, you can: • Find an in-network doctor, hospital, or other provider • Log in to your Blue Access for MembersSM account to find

coverage and benefits information, Explanation of Benefits statements (EOBs), change your PCP, or chat with a BCBSTX Personal Health Assistant

• Read important news and information about your health plan

Blue Access for MembersBlue Access for Members is your secure online participant portal where you can: • View your claims and EOBs • Find an in-network doctor, hospitals, or other provider • Select and change your PCP • Check the costs of services covered under your plan • Download a temporary ID card • Confirm your prior authorizations and referrals on file

BCBSTX AppWith the BCBSTX Mobile App, your benefits are at your fingertips, wherever you are.

You can: • Find an in-network doctor, hospital or urgent care

facility near you • Chat with a BCBSTX Personal Health Assistant1

• View prior authorizations and referrals • Check the status or history of a claim • Request an ID card or save a digital copy to your phone

1 BCBSTX Personal Health Assistants do not take the place of your doctor. Personal Health Assistants are available by chat Monday – Friday 8 a.m. - 5 p.m. CT.

Text BCBSTXAPP to 33633 to get a link to download the app.

Chat with a BCBSTX Personal Health Assistant via Blue Access for Members or the BCBSTX Mobile App Monday-Friday 8 a.m. - 5 p.m. CT


SELECTING A PRIMARY CARE PHYSICIAN

Having an in-network primary care physician (PCP) can help you control costs, save time, and improve your overall health. HealthSelect of Texas participants must choose an in-network PCP to get the highest level of benefits and save the most money. HealthSelect Out-of-State, Consumer Directed HealthSelect and HealthSelect Secondary participants may also benefit from having an in-network PCP, even though it is not required.

Why should I select a PCP? • Seeing a PCP is one of your most convenient and lowest-

cost options for care. If you’re sick, it’s easier to schedule an appointment as an established patient than to find a doctor accepting new patients. Plus, visits to your in-network PCP are less expensive than visits to urgent care centers or specialists.

• When you have a PCP, you have access to a doctor that knows you and your medical history. Your PCP can help you take care of your preventive health needs, as well as many non-emergency health issues, including colds, flus, rashes and allergies.

PCPs for HealthSelect of Texas ParticipantsTo receive in-network benefits, HealthSelect of Texas participants must obtain referrals from their PCP before seeing specialists for care. If you do not have a referral on file before you see a specialist, you will pay more, because your visit will be considered out-of-network.

Remember, you can change your PCP at any time. If you have not selected a PCP or if you want to change your PCP, follow the instructions below.

To select or to change your PCP:

You do not need a referral for: • Chiropractic visits • Covered vision care, including routine and

diagnostic eye exams • Mental health counseling • OB/GYN visits • Occupational therapy, physical therapy or

speech therapy1

• Virtual visits, urgent care centers or convenience care clinics

1 Treatment plans beyond the initial visit for occupational therapy, physical therapy and speech therapy require prior authorization.

You can either call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039 or go online and follow these instructions:1. Go to www.healthselectoftexas.com2. Click on “Log In” in the upper right-hand corner. If you

already have a Blue Access for Members℠ account, log in. If you do not have an account yet, click “Register Now” and use your medical ID card to create an account.

3. Once you’re logged in, go to the “Doctors and Hospitals” tab.

4. Click “Select Primary Care Physician” and enter information about your location and what you’re looking for in a PCP.


PCPs for HealthSelect of Texas ParticipantsTo receive in-network benefits, HealthSelect of Texas participants must obtain referrals from their PCP before seeing specialists for care. If you do not have a referral on file before you see a specialist, you will pay more, because your visit will be considered out-of-network.

Remember, you can change your PCP at any time. If you have not selected a PCP or if you want to change your PCP, follow the instructions below.

To select or to change your PCP:

MENTAL HEALTH AND WELLBEING

HealthSelect of Texas and Consumer Directed HealthSelect plans offer mental health benefits1 to support your well-being. HealthSelect plans include coverage for both inpatient and outpatient treatment.

Referrals are not required for mental health care for any of the HealthSelect plans. However, prior authorization may be required for some intensive therapy programs and inpatient treatment.

Your mental health benefits might be used for: • Office visits to a licensed counselor • Inpatient intensive therapy program for addiction • Outpatient intensive therapy for a severe mental

health disorderMental health services can be used to treat a variety of concerns, including the following:

1 BCBSTX contracts with Magellan Healthcare to manage mental health benefits. Magellan processes mental health claims, manages the mental health provider network and operates a customer service center for HealthSelectSM℠of Texas and Consumer Directed HealthSelectSM. BCBSTX manages mental health benefits and claims processing for HealthSelectSM Out-of-State participants, HealthSelectSM Secondary participants and Consumer Directed HealthSelect participants who live or work outside the State of Texas.

• Alcohol and drug use • Anger management • Anxiety • Bipolar disorder • Depression • Domestic violence • Financial stress

• Grief • Post-traumatic stress

disorder (PTSD) • Schizophrenia and

schizoaffective disorder • Suicidal thinking • Stress

How to get careThere are many types of mental health providers that offer a range of mental health care, but your PCP is a great place to start talking about mental health. They can tell you about mental health support nearby, recommend a mental health provider or even prescribe medication.

Though input from your PCP can be helpful, if you know what type of care you are seeking, you can find an in-network provider without checking with your PCP first. To make the most of your benefits and help you save money, be sure to choose an in-network provider.

If you’re not sure where to start, your in-network PCP can talk with you about a course of action and may recommend a provider or prescribe medication.

To talk with a counselorYou can get help with a mental health or substance use issue, any time. Call the 24/7 HealthSelect Mental Health Line at (800) 442-4093 to talk with a counselor about mental health or substance use issues.

Choose a mental health provider:

Visit www.healthselectoftexas.com and click“Find a Doctor/Hospital” to access the Provider Finder. Click “Mental health care” and then choose your preferred provider type.

OR

Call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday–Friday, 7 a.m. - 7 p.m. CT and Saturday, 7 a.m. - 3 p.m. CT.


OPTIONS FOR CARE

Sometimes it’s easy to know when you should go to an emergency room (ER), such as when you have severe chest pain or unstoppable bleeding. At other times, it’s less clear.

Where do you go when you have an urgent situation that’s not life threatening? You have choices and options for care. And it’s important to know when to use each option because some can be very expensive for you and you’ll be paying bills long after you’ve recovered.

Doctor’s Office — $Generally, it’s the best place to go for non-emergency care. Your doctor knows you and your medical history and can treat you, or refer you to a specialist if needed.

Virtual Visits — $0If you cannot see your regular doctor, virtual visits can be a convenient option for non-emergency medical care. And they are available at no cost to you if you are enrolled in HealthSelect of Texas, HealthSelect Out-of-State, or HealthSelect Secondary. Consumer Directed HealthSelect participants must meet their annual deductible and then coinsurance will apply. Learn more on page 11.

Retail Health Clinic — $$You will see these in pharmacies and stores. You do not need an appointment and they can provide treatment for minor medical issues usually at a lower cost than urgent care.

Urgent Care — $$$If you need x-rays or stitches and you can’t get in to your doctor, urgent care can provide immediate non-emergency treatment.

Hospital Emergency Room — $$$$If your situation is life threatening, go to the nearest hospital or call 911. True emergencies are covered at the in-network level of benefits.

H

If you are enrolled in HealthSelect of Texas or HealthSelect Out-of-State, when you seek care at an out-of-network freestanding ER that is not affiliated with a hospital, you will pay more:1 • $300 copay • No deductible if true emergency but out-of-network

deductible applies if not a true emergency • The plan pays 80% of the out-of-network allowable

amount if true emergency and 60% of the out-of-network allowable amount if not a true emergency.

• Even if your visit is a true emergency, you may be responsible for any difference between the amount billed by the facility and the out-of-network allowable amount, which could be significant.

Freestanding Emergency Room: The highest cost care — $$$$$$

You may see a standalone emergency room in the middle of a retail shopping mall or in your neighborhood. Most freestanding emergency rooms (ERs) facilities and providers are not affiliated with a hospital and are out-of-network. This means you will pay a significant amount out-of-pocket.

Freestanding ERs can be confused with urgent care clinics or hospital-based ERs. While they might look like inviting and convenient facilities for care, your costs will be high.

In many cases, if you are in a true emergency, a freestanding ER will have to transfer you to a real hospital. This means you’ll receive bills from two emergency facilities including additional transportation and ambulance fees.

Get answers day or night with 24/7 Nurseline

If you’re not sure where to go for care, call the 24/7 Nurseline and speak with a registered nurse toll-free at (800) 581-0368. Call any time, any day of the year.2

1 Consumer Directed HealthSelect and HealthSelect Secondary participants should refer to the Master Benefit Plan Document.

2 For medical emergencies, call 911. 24/7 Nurseline is not a substitute for a doctor’s care. Talk to your doctor about any health questions or concerns.


VIRTUAL VISITS

HealthSelect offers you convenient options for care. With virtual visits, you can consult a board-certified doctor anytime online or by phone. Doctors can diagnose simple, non-emergency medical health conditions and prescriptions can be sent directly to your pharmacy.1

1 In the event of an emergency, this service should not take the place of an emergency room or urgent care center. MDLIVE and Doctor On Demand doctors do not take the place of your primary care doctor. Internet/Wi-Fi connection is needed for computer access. Data charges may apply. Check your cellular data or internet service provider’s plan for details. Non-emergency medical service in Idaho, Montana and New Mexico is limited to interactive audio/video (video only). Non-emergency medical service in Arkansas is limited to interactive audio/video (video only) for initial consultation. Service availability depends on location at the time of consultation. Vir tual visits are subject to the terms and conditions of your benefit plan, including benefits, limitations, and exclusions. The telemedicine services made available through Doctor On Demand are provided by licensed physicians practicing within a group of independently owned professional practices collectively known as “Doctor On Demand Professionals.” These professional practices provide services via the Doctor On Demand telehealth plat form. Doctor On Demand, Inc. does not itself provide any physician, mental health or other healthcare provider services. MDLIVE and Doctor On Demand operate subject to state regulations and may not be available in certain states. MDLIVE and Doctor On Demand are not insurance products nor prescription fulfillment warehouses. MDLIVE and Doctor On Demand do not guarantee that a prescription will be writ ten. MDLIVE and Doctor On Demand do not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. MDLIVE and Doctor On Demand physicians reserve the right to deny care for potential misuse of services. MDLIVE and Doctor On Demand are independent companies that operate and administer the vir tual visit program and are solely responsible for their operations and that of their contracted providers. MDLIVE® and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without writ ten permission.

Get treatment for: • Allergies • Bladder/Urinary

Tract Infection • Bronchitis • Cold and flu

• Headache • Nausea • Pink Eye • Sore throat • Rash

Create your virtual visits account now and be ready when you need it.

Doctor On Demand®

• Doctorondemand.com • (800) 997-6196

MDLIVE®

• Mdlive.com/healthselect • (800) 770-4622

TTY: (800) 770-5531

Virtual visits are available at no cost to you if you are enrolled in HealthSelect of Texas, HealthSelect Out-of-State or HealthSelect Secondary. If you are enrolled in Consumer Directed HealthSelect, you will be required to meet the annual deductible before visits are covered, subject to coinsurance after the deductible is met.

Get started using virtual visits:1. You have the same benefit with two virtual visit

providers: Doctor On Demand and MDLIVE. The choice is yours.

2. Go online to Doctor On Demand or MDLIVE OR download their apps from Google Play or the App Store.

3. Have your medical ID card handy to set up your account.4. When you are ready for a virtual visit, choose a doctor.

You can schedule an appointment now, or for a time in the future that’s more convenient for you.

5. Consult by phone or video with a board-certified doctor.


SAMPLE EXPLANATION OF BENEFITS

An Explanation of Benefits (EOB) is a notification provided to members when BCBSTX processes a health care claim. The EOB shows how the claim was processed and how much you may owe your provider. The EOB is not a bill. Your provider may bill you separately.

The EOB has four major sections:Subscriber Information and Total of Claim(s)

Includes the participant’s name, address, member ID number and group name and number. The Total of Claims table shows you the amount billed by your provider, any discounts applied by the HealthSelect plan, and the amount you may owe the provider.

Service Detail for each claim includes: • Patient and provider information • Claim number and when it was processed • Service dates and descriptions • The amount billed • The discounts or other reductions subtracted

from amount billed • Total amount covered • The amount you may owe (your responsibility)

Summary shows you what the plan covers for each claim and your responsibility including:

Plan Provisions • The amount covered • Less any amounts you may owe, like deductible, copay

and coinsurance

Your Responsibility • Deductible and copay amount • Your share of coinsurance • Amount not covered, if any • Amount you may owe the provider. You may have paid

some of this amount, like your copay, at the time you received the service.


A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

EXPLANATION OF BENEFITSAn EOB is a statement showing how claims were processed.This is not a bill. Your provider(s) may bill you directly for anyamount you may owe. KEEP FOR YOUR RECORDS.

SUBSCRIBER INFORMATIONEMPLOYEES RETIREMENT SYSTEM OF TEXAS

Member ID#: JEA123456789 Group #: 000238000

TOTAL OF CLAIM

Amount Billed $3,400.00

Discounts, reductions and payments - $2,800.00

You may have to pay your provider $600.00

SERVICE DETAIL - CLAIM (1 )

PATIENT: SUSAN SMITH PROVIDER: FERNANDO G TORRES CLAIM #: 123456T14950X

SERVICE DATE: 10/01/2017 Processed: 10/18/2017

PLAN PROVISIONS YOUR RESPONSIBILITY

Service Description Amount billedDiscounts and

reductionsAmount covered

(allowed)*Deductible andcopay amount

CoinsuranceAmount not

covered

Emerg Accident Care 3,000.00 3,000.00 600.00

Emerg Accident X-Ray 200.00 (1) 200.00

Emerg Accident Lab 200.00 (1) 200.00

CLAIM TOTALS $3,400.00 $400.00 $3,000.00 $0.00 $600.00 $0.00

*Amount covered (allowed) reflects the savings we’ve negotiated with your provider for this service. Your deductible, coinsurance and copay are based on the allowed amount. Your share of coinsurance is apercentage of the allowed amount after the deductible is met.

(1) This service is considered part of another procedure performed on this date and should not be billed as a separate charge. No payment can be made. Based on our agreement with this provider, you arenot responsible for this charge.

Total covered benefits approved for this claim: $2,400.00 to FERNANDO G TORRES PA on 10-18-17.

SUMMARY (1)

PLAN PROVISIONS

Amount covered (allowed)* $3,000.00

Deductible and copay amount $0.00

Coinsurance - $600.00

Total $2,400.00

YOUR RESPONSIBILITY

Deductible and copay amount $0.00

Coinsurance + $600.00

Amount not covered $0.00

You may have to pay your provider $600.00

Fraud Hotline at 800-543-0867Health care fraud affects health care costsfor all of us. If you suspect any person orcompany of defrauding or attempting todefraud Blue Cross and Blue Shield ofTexas, please call our toll-free hotline. Allcalls are confidential and may be madeanonymously. For more information abouthealth care fraud, please go to bcbstx.com.

Patient: SUSAN FLUMEBenefit Period: 09-01-17 Through 12-31-17 To date this patient has met $2,735.49 of her/his $6,550.00 Out-of-pocket Expense.

Benefit Period: 09-01-17 Through 12-31-17 To date $3,095.49 of the Family $13,100.00 Out-of-pocket Expense has been met.

Jon Smith1234 Cedar RoadAPT #2Any Town, TX 76065

Log in at www.healthselectoftexas.com to see plan and claim details or to contact us through our secure Message Center.

Have questions about this EOB? Personal Health Assistants are here to help! (800) 252-8039

P.O. Box 660044Dallas, TX 75266-0044

1. Participant’s name and mailing address

2. Participant’s member ID and group number

3. Summary box for all claims including total billed by the provider, and discounts, reductions or payments made, and the amount you may owe

4. Detailed claim information for each claim

5. Provider information

6. Claim number and date the claim was processed

7. Patient name and service date

8. Service description

9. Amount billed for each service

10. The amount covered (allowed)for each service and the discounts or reductions subtracted from the amount your provider billed

11. Your share of the costs

12. Claim summary with amount covered less your responsibility

13. Health Care Fraud Hotline

14. Deductible and/or out-of-pocket expense information


Managing weight is difficult for many people, but a support system can make it easier. Your HealthSelect medical benefits include access to two online weight management programs.1 If you meet certain eligibility requirements, you can apply for enrollment in Naturally Slim® or Real Appeal® at no cost to you.2

You are eligible if you are:

1 Naturally Slim and Real Appeal are available at no cost to employees, retirees and dependents enrolled in a HealthSelect plan (excluding Medicare-primary participants) who are 18 or older and have a BMI of 23 or higher.2 Participants may choose either program, but can only participate in one program at any given time.3 Naturally Slim and Real Appeal are independent companies that provide wellness services for HealthSelect of Texas and Consumer Directed HealthSelect. They are solely responsible for the products and services that they provide.

Your acceptance is not guaranteed.

• an employee, retiree or dependent enrolled in a HealthSelect plan (excluding Medicare-primary participants)

• 18 or older, and • have a BMI of 23 or higher.3

Focuses on changing your eating habits so you can still eat the foods you love while losing weight and improving your health.

Log on when it’s convenient for a series of ten weekly sessions hosted by Naturally Slim nutrition and health specialists.

To enroll, go to www.naturallyslim.com/healthselect

Helps you take small steps that lead to lasting weight loss. Program can be tailored to your goals, preferences and lifestyle.

Participate in weekly online group sessions led by a Transformation Coach.

To enroll, go to www.healthselect.realappeal.comLearn more about tools and programs available to help you meet your weight management goals by visiting www.healthselectoftexas.com and going to the “Health and Wellness/Incentives” tab, then “Weight Management.”

WEIGHT MANAGEMENT PROGRAMS


WELLNESS RESOURCES

Well onTarget®

Well onTarget is an online wellness portal that offers personalized resources and incentives to support you on your wellness journey. Get the support you need to make healthy choices while being rewarded for your hard work!

The Well onTarget experience starts with your personal login.1. Go to www.healthselectoftexas.com2. Click on “Log In” in the upper right-hand corner. If you

already have a Blue Access for Members account, log in. If you do not have an account yet, click “Register Now” and use your medical ID card to create an account.

3. Once you’re logged in to Blue Access for Members, click “Well onTarget” under the Quick Links on the left.

Well onTarget offers: • Health Assessment • Symptom checker • Wellness coaching

• Self-directed health and wellness courses on topics like losing weight, quitting tobacco and managing stress

Health AssessmentThe Health Assessment (HA), sometimes referred to as the Health Risk Assessment, uses adaptable questions to learn more about you. After you take the HA, you will get a personal wellness report. This confidential report offers you tips for living your healthiest life.

Blue PointsSM

Blue Points can help motivate you to maintain a healthy lifestyle. Earn points for participating in wellness activities. You can redeem points in the online shopping mall. The program gives you points instantly, so you can use them right away.

Fitness ProgramFitness can be easy, fun and affordable. The Fitness Program is a flexible membership program that gives you unlimited access to a nationwide network of more than 9,000 fitness centers. If you want, you can choose one gym close to home and one near work. And you can visit gyms while you’re on vacation or traveling for work.

It’s easy to join the Fitness Program! Just call the toll-free number (888) 762-BLUE (2583) Monday—Friday, 8 a.m. - 9 p.m. in any continental U.S. time zone.1

Other program perks include: • No long-term contract: Membership is month to

month. Monthly fees are $25 per month per member, with a one-time enrollment fee of $25 per member.

• Blue Points: Get 2,500 points for joining the Fitness Program. Earn additional points for weekly visits.2

• Web resources: You can go online to locate gyms and track your visits.

• WholeHealth Living™ Discount Program: Save money through a nationwide complementary and alternative medicine network of 40,000 health and well-being providers, such as massage therapists, personal trainers and nutrition counselors.

1 The Fitness Program is provided by Healthways, Inc., an independent contractor that administers the Prime Network of fitness centers. The Prime Network is made up of independently owned and operated fitness centers.

2 Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal at wellontarget.com for further information.

If your employer allows you to receive wellness incentives for completion of a health assessment, take the OnMyWay Health Assessment and provide your Benefits/Wellness Coordinator with a certificate of completion.

Look for this icon to see which healthy activities will earn you Blue Points!


HEALTHSELECT OF TEXAS

HealthSelect of Texas is a point-of-service health plan available to active employees, participants not enrolled in Medicare, and their eligible dependents who live or work in the State of Texas. If you are enrolled in HealthSelect of Texas, you should choose an in-network primary care physician (PCP). Your PCP coordinates your care and manages any referrals you may need to see specialists. If you see an in-network provider, you will not have to meet a deductible before the plan begins to pay for your health care services. There is a $500 per person/$1,500 per family deductible if you see a provider who is not in the HealthSelect network.

PCP SelectionYou should choose a PCP to coordinate your health care. You can select or change your PCP by logging in to Blue Access for MembersSM or by calling a BCBSTX Personal Health Assistant toll-free at (800) 252-8039.

1 Treatment plans beyond the initial visit for occupational therapy, physical therapy and speech therapy require prior authorization.

Referrals You must obtain referrals from your PCP before seeing specialists for care. To receive in-network benefits, your PCP will need to submit a referral to BCBSTX before your specialist visit. If you do not have a referral on file before you see a specialist, you will pay more because your visit will be considered out-of-network.

You do not need a referral for the following services: • Chiropractic visits • Eye exams (both routine

and diagnostic) • Mental health counseling • OB/GYN visits

• Occupational therapy, physical therapy or speech therapy1

• Virtual visits, urgent care centers and convenience care clinics

Prior AuthorizationYou need prior authorization for certain covered health services. Usually, your network PCP and other network providers will obtain prior authorization before they provide these services to you. However, in some cases you will need to obtain prior authorizations yourself.

Health services that require a prior authorization include, but are not limited to: • Durable medical

equipment and supplies more than $1,000

• High-tech radiology (CT, PET, MRI, Nuclear Stress Test, etc.)

• Home health services

• Inpatient hospital stays, including inpatient mental health treatment

• Outpatient surgical procedures

• Skilled nursing services

BCBSTX Personal Health Assistants can help you if you have questions about your HealthSelect benefits, including what services require referrals and prior authorizations. Personal Health Assistants can also work with your doctor’s office to help coordinate referrals and prior authorizations.


HEALTHSELECT OF TEXASEffective September 1, 2018 (excluding out-of-pocket maximum which is effective January 1, 2019)

5/26/2017Chart_2017_Comparison

Employee and Non-Medicare-Eligible RetireeHEALTH PLANS COMPARISON CHART

Effective September 1, 2017

Benefi tsHealthSelectSM of Texas

Network Non-Network

Annual deductible None $500 per person1

$1,500 per family1

Out-of-pocket coinsurance maximum2

$2,000 per personper calendar year1


Total out-of-pocket maximum(including deductibles, coinsurance and copays)4,5

$6,650 per person1 $13,300 per family1 None

Primary care physician required Yes No

Primary care physicians’ offi ce visit $25 copay 40%*

Mental health care

a. Outpatient physician or mental health provider offi ce visits

$25 copay 40%*

b. Hospital mental health inpatient stay9

$150/day copay plus 20% ($750 copay max, up to 5 days per hospital stay. $2,250 copay max per calendar year per person)

$150/day copay plus 40%* ($750 copay max, up to 5 days per hospital stay. $2,250 copay max per calendar year per person)

c. Outpatient facility care (partial hospitalization/ day treatment and extensive outpatient treatment)7

20% 40%*

Physicals# No charge 40%*

Specialty physicians’ offi ce visits $40 40%*

Routine eye exam, one per year per participant

$40 40%*

Routine preventive care# No charge 40%*

Diagnostic x-rays, lab tests, and mammography

20% 40%*

Offi ce surgery and diagnostic procedures 20% 40%*

High-tech radiology (CT scan, MRI, and nuclear medicine)7,8,9

$100 copay plus 20%

$100 copay plus 40%*

Urgent care clinic $50 copay plus 20% 40%*

Benefi tsHealthSelectSM of Texas

Network Non-NetworkMaternity care doctor charges only#; inpatient hospital copays will apply

No charge for routine prenatal appointments$25 or $40 for fi rst post-natal visit6

40%*

Chiropractic care

a. Coinsurance 20%; $40 copay plus 20% with offi ce visit 40%*

b. Maximum benefi t per visit $75 $75

c. Maximum visits Each participant Per calendar year

30 30

Inpatient hospital(semi-private room and day’s board, and intensive care unit)9

$150/day copay plus 20% ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)

$150/day copay plus 40%* ($750 copay max-up to 5 days per hospital stay, $2,250 copay maxper calendar year per person)

Emergency care$150 plus 20% (if admitted copay will apply to hospital copay)

$150 plus 20% (if admitted copay will apply to hospital copay)12

Outpatient surgery other than in physician’s offi ce9

$100 copay plus 20%


Bariatric surgery9,10,11

a. Deductible $5,000 b. Coinsurance 20% c. Lifetime max $13,000

Not covered

Hearing aids Plan pays up to $1,000 per ear every three years (no deductible).

Durable medical equipment9 20% 40%*

Ambulance services (non-emergency)9 20% 20%

*Note: 40% coinsurance after you meet the annual out-of-network deductible

1 Applies to calendar year, January 1 - December 31, 2019. Prior to January 1, 2019 the 2018 calendar year total in-network out-of-pocket maximum of $6,550 per person and $13,100 per family applies. 2 Does not include copays.

3 Applies to plan year, September 1 - August 31. 4 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a participant’s total network out-of-pocket maximum could contain a combination of coinsurance and/or copayments. 5 Includes medical and prescription drug copays, coinsurance and deductibles. Excludes non-network and bariatric services. 6 Copay depends on whether treatment is given by PCP or specialist. 7

Outpatient testing only. Does not apply to inpatient services. 8 No copay if high-tech radiology is performed during ER visit or inpatient admission. 9 Preauthorization required. 10 Active employees only; see health plan for additional requirements/limitations. 11 The deductible and coinsurance paid for bariatric surgery does not apply to the total out-of-pocket maximum. 12 Benefi ts shown do not apply to out-of-network freestanding ERs. For information about this coverage, see the Master Benefi t Plan Document. # Under the Affordable Care Act, certain preventive and women’s health services are paid at 100% (at no cost to the participant) dependent upon physician billing and diagnosis. In some cases, the participant will still be responsible for payment on some services.


Living or working outside of Texas?HealthSelect Out-of-State is available only to active employees, participants not enrolled in Medicare, and their eligible dependents living or working outside the state of Texas.

Some important things to know about the HealthSelect Out-of-State plan: • You do not need to select a primary care physician (PCP) • You do not need a referral to see a specialist • HealthSelect Out-of-State benefits are the same as

HealthSelect of Texas • You do not need to meet a deductible before the plan

begins to pay for covered health services in-network • You will have a copay for certain services like PCP and

specialist office visits

If you move outside Texas, please contact the Employees Retirement System of Texas to update your address so that you can move to HealthSelect Out-of-State: go to www.ers.texas.gov or call toll-free (877) 275-4377.

If you live in Texas but have an eligible dependent living in another state, call a Personal Health Assistant from BCBSTX toll-free at (800) 252-8039 to move your dependent to HealthSelect Out-of-State.

Why you may still want to have a PCPEven though you are not required to have a PCP if you are enrolled in HealthSelect Out-of-State, having a PCP can be a boost to your health.

Your PCP: • Will get to know you – your health history, your

medications and your lifestyle • Can treat many non-urgent health issues like

ear infections, rashes, allergies, fevers, colds, flu and much more

• Will address routine medical care, such as physicals and yearly exams

• Is your health coach who can show you better ways to stay healthier

• Can decide if you need any tests or if you should see a specialist

• Can help you with specialized care for a chronic health issue, such as asthma, diabetes or a heart problem

If you see a provider who is not in the network, you will need to meet a deductible of $500 per person/$1,500 per family.

HEALTHSELECT OUT-OF-STATE


HEALTHSELECT OUT-OF-STATE




Benefi tsHealthSelect Out-of-State

Network Non-Network


$1,500 per family1






Primary care physician required No No

Primary care physicians’ offi ce visit $25 copay 40%*

Mental health care


20% 40%*





20% 40%*


Specialty physicians’ offi ce visits $40 40%*


$40 40%*



20% 40%*

Offi ce surgery and diagnostic procedures 20% 40%*


$100 copay plus 20%


Urgent care clinic $50 copay plus 20% 40%*

Benefi tsHealthSelect Out-of-State



40%*

Chiropractic care

a. Coinsurance 20%; $40 copay plus 20% with offi ce visit 40%*



30 30



$150/day copay plus 40%* ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)




$100 copay plus 20%




Not covered

Hearing aids

Plan pays up to $1,000 per ear every three years (no deductible).

Durable medical equipment9 20% 40%*

Ambulance services (non-emergency)9 20% 20%

*Note: 40% coinsurance after you meet the annual out-of-network deductible

1 Applies to calendar year, January 1 - December 31, 2019. Prior to January 1, 2019 the 2018 calendar year total in-network out-of-pocket maximum of $6,550 per person and $13,100 per family applies. 2 Does not include copays. 3

Applies to plan year, September 1 - August 31. 4 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a participant’s total network out-of-pocket maximum could contain a combination of coinsurance and/or copayments. 5 Includes medical and prescription drug copays, coinsurance and deductibles. Excludes non-network and bariatric services. 6 Copay depends on whether treatment is given by PCP or specialist. 7


Effective September 1, 2018 (excluding out-of-pocket maximum which is effective January 1, 2019)


Consumer Directed HealthSelect Consumer Directed HealthSelect is a high-deductible health plan paired with a health savings account (HSA)1, available to active employees, participants not enrolled in Medicare, and their eligible dependents who live or work in the State of Texas.

Some important things to know about the Consumer Directed HealthSelect plan: • No primary care physician (PCP) required • Referrals not needed to see specialists • Deductible must be met before any services (other

than preventive care) are paid for by the plan: $2,100 in-network deductible per person/$4,200 per family and includes in-network medical and prescription drug expenses

• Preventive services – like annual check-ups and preventive vaccinations – covered at 100% when you visit an in-network doctor, even if you haven’t met the deductible

• This plan is paired with an HSA to help you pay for higher out-of-pocket costs

1 Participants who are enrolled in any part of Medicare (Part A, B, C and/or D), receive benefits under TRICARE or TRICARE for Life, or have a health care flexible spending account (like a TexFlex health care account) in the same plan year are not eligible for an HSA.

Important Information about HSAs: HSA contributions and limits may change from year to year, or based on eligibility requirements and the participant ’s age. Maximums are set by the IRS and include both pre-tax and post-tax contributions to an HSA. HSAs have tax and legal ramifications.

Be ready for out-of-pocket costs with an HSA You can use your HSA to pay for qualified medical expenses, including your deductible and coinsurance. • The State of Texas will add pre-tax dollars to your HSA

account each month: in FY19, the state will contribute $45 per month ($540 per year) for individual coverage and $90 per month ($1,080 per year) for family coverage

• If you are an active employee, make tax-free contributions to your HSA through payroll deductions or independently

• Payroll deductions are not available if you are retired, but you can make contributions independently

• HSAs are portable: you can use your HSA on qualified medical expenses. If you change to a different health plan or change employers, the money in your HSA stays with you

• Your unused HSA balance will carry over from one year to the next, so you won’t lose money in your account at the end of the year

• Your HSA is administered by a separate bank — not BCBSTX. Go to www.healthselectoftexas.com and click “Consumer Directed HealthSelect” for more information about your HSA bank account.

CONSUMER DIRECTED HEALTHSELECT

If you see a provider outside the plan’s network, there is a $4,200 per person/$8,400 per family deductible.


CONSUMER DIRECTED HEALTHSELECT




Benefi tsConsumer Directed HealthSelectSM

Network Non-Network

Annual deductible$2,100 per person1

$4,200 per family1

$4,200 per person1 $8,400 per family1


None None



Primary care physician required No No

Primary care physicians’ offi ce visit 20%** 40%*

Mental health care


20%** 40%*


20%** 40%*


20%** 40%*


Specialty physicians’ offi ce visits 20%** 40%*


20%** 40%*



20%** 40%*

Offi ce surgery and diagnostic procedures 20%** 40%*


20%** 40%*

Urgent care clinic 20%** 40%*

Benefi tsConsumer Directed HealthSelectSM


No charge for routine prenatal appointments 20%** for fi rst post-natal visit

40%*

Chiropractic care

a. Coinsurance 20%** 40%*



30 30


20%** 40%*

Emergency care 20%** 20%**12


20%** 40%*

Bariatric surgery9,10,11 Not covered Not covered

Hearing aids Plan pays up to $1,000 per ear every three years (after deductible is met).

Durable medical equipment9 20%** 40%*

Ambulance services (non-emergency)9 20%** 20%**

*Note: 40% coinsurance after you meet the annual out-of-network deductible **Note: 20% coinsurance after you meet the annual in-network deductible.

1 Applies to calendar year, January 1 - December 31, 2019. Prior to January 1, 2019 the 2018 calendar year total in-network out-of-pocket maximum of $6,550 per person and $13,100 per family applies. 2 Does not include copays. 3

Applies to plan year, September 1 - August 31. 4 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a participant’s total network out-of-pocket maximum could contain a combination of coinsurance and/or copayments. 5 Includes medical and prescription drug copays, coinsurance and deductibles. Excludes non-network and bariatric services. 6 Copay depends on whether treatment is given by PCP or specialist. 7




HEALTHSELECT SECONDARY

HealthSelect Secondary HealthSelect Secondary is available to participants and their eligible dependents enrolled in Medicare as well as participants with an address on file with ERS that is outside the United States.1 This plan has a different network than HealthSelect of Texas because it coordinates your medical plan coverage with Medicare. Usually, HealthSelect Secondary pays for services only after Medicare has paid first. If you are required to pay a portion of the cost, you need to meet a deductible of $200 per person/$600 per family before HealthSelect Secondary begins to pay for services (other than preventive care).

Here are some things to know: • Medicare and HealthSelect Secondary deductibles

run concurrently • You do not need to choose a primary care physician (PCP) • You do not need a referral from a PCP to see a specialist • Preventive services — like annual check-ups and

preventive vaccinations — are covered at 100% when you visit a doctor that accepts Medicare, even if you haven’t met the deductible

1 Return to work retirees may have HealthSelect Secondary as their primary coverage, unless they choose active coverage.2 If you do not qualify for free part A, provide a copy of the SSA documentation that you do not qualify for free Part A to Blue Cross and Blue Shield of Texas, If you turned 65 and retired prior to September 1, 1992 you are not required

to purchase Part B.

It’s important to know how HealthSelect Secondary coverage works with Medicare.

If you are retired from the State of Texas and are eligible for Medicare (due either to your age or a disabling condition) you should enroll in Medicare Part A and Medicare Part B.2 If you do not have this coverage, you will have to pay the charges that Medicare would have paid had you been enrolled in it.

It is possible for you and family members with HealthSelect to have different coverage, depending on age and Medicare eligibility. For example, if both you and your spouse are enrolled in HealthSelect and you become eligible for Medicare, but your spouse is not eligible for Medicare, Medicare will be the primary benefit plan for you, and HealthSelect will continue to be the primary plan for your spouse. This is true until your spouse turns 65 and/or becomes eligible for Medicare.

Your prescription benefits are managed separately. Go to www.healthselectoftexas.com and click “Prescription Drug Benefits” to access information about your prescription drug benefits.

Why you may still want to have a PCPYou are not required to have a PCP for HealthSelect Secondary. Also, referrals for a specialist are not required. But, having a PCP can be a boost to your health.

Your PCP: • Will get to know you – your health history, your

medications and your lifestyle • Can treat many non-urgent health issues like

ear infections, rashes, allergies, fevers, colds, flu and much more

• Will address routine medical care, such as physicals and yearly exams

• Can show you better ways to stay healthier • Will decide if you need any tests or if you should

see a specialist • Can help you with specialized care for a chronic health

issue, such as asthma, diabetes or a heart problem


HEALTHSELECT SECONDARY




Benefi ts1 HealthSelect Secondary

Annual deductible$200 per individual$600 per family

Total out-of-pocket maximum7 (including deductibles, coinsurance and copays).8,9

$6,650 per person$13,300 per family

Out-of-pocket coinsurance maximum1 $3,000 per person

Offi ce visits in conjunction with an illness or injury $0 copay / 30%2, 3 coinsurance

Specialty physician offi ce visit $0 copay / 30%2, 3 coinsuranceDiagnostic tests andx-rays, including allergy testing $0 copay / 30%2, 3 coinsurance

Diagnostic mammography $0 copay / 30%2, 3 coinsuranceDiagnostic lab services $0 copay / 30%2, 3 coinsurancePreventive services†

(such as screening mammogram, physical, well woman exam, prostate cancer screening, etc.)

$0

Offi ce surgery and diagnostic procedures $0 copay / 30%2, 3 coinsurance

Immunizations† $0High-tech radiology(CT scan, MRI, and nuclear medicine) $0 copay / 30%2, 3 coinsurance

Allergy injections and serum $0 copay / 30%2, 3 coinsuranceRoutine eye exam 30%2,4

Routine hearing test 30%2

Diagnostic speech and hearing testing $0 copay / 30%2, 3 coinsurance

Speech and hearing therapy $0 copay / 30%2, 3 coinsurance

Hearing aids $1,000 benefi t allowance per ear every 3 years

Chiropractic care $0 copay / 30%2, 3 coinsuranceUrgent care clinic $0 copay / 30%2, 3 coinsuranceEmergency care5 $0 copay / 30%2, 3 coinsuranceInpatient hospital(semi-private room and days board, and intensive care unit)

$06 If provider doesn’t accept Part A, then coverage is 30%2, 3

Outpatient surgery $0 copay / 30%2, 3 coinsurance

Skilled nursing facility• No deductible• Plan pays 100%

Home health care

$0 copay/30%2, 3 coinsurance for home infusion therapy Plan pays 100% for all other home health care services with a maximum of 100 visits per calendar year

Hospice $0 copay / 30%2, 3 coinsurance

Ambulance$0 copay/30% 2,3 coinsurance. Emergency care only. Not applicable to non-emergent transportation services.

Private duty nursing30%2

• Unlimited hours

Benefi ts1 HealthSelect Secondary

Mental health

a. Outpatient physician or mental health provider offi ce visits $0 copay / 30%2, 3 coinsurance

b. Hospital mental health inpatient stay(semi-private room and days board, and intensive care unit)

$06 If provider doesn’t accept Part A, then coverage is 30%2, 3

c. Outpatient facility care(partial hospitalization/day treatment and extensive outpatient treatment)

$0 copay / 30%2, 3 coinsurance

1 Benefi ts are paid on allowable amounts; using providers who contract with Blue Cross and Blue Shield of Texas will protect you from liability for amounts over the allowable amount.

2 After payment of deductible. HealthSelect note: Medicare and HealthSelect deductibles run concurrently. Member may be responsible for some charges when the provider does not accept Medicare assignment.

3 Payment amount is dependent upon the coordination of benefi ts (COB) between HealthSelect and original Medicare. Sometimes this means your expense is $0, but charges will vary depending upon COB. Please reference your Summary of Benefi ts for more information.

4 One per calendar year.5 Benefi ts shown do not apply to out-of-network freestanding ERs. For information about this coverage, see the

Master Benefi t Plan Document.6 In the event that the provider/facility does not accept Medicare assignment (so the charges are not covered by

Medicare and therefore not subject to COB), you may be responsible for copay(s) and/or a coinsurance. Please see your Summary of Benefi ts for more information.

7 Applies to calendar year, January 1 – December 31, 2019. Prior to January 1, 2019 there is no out-of-pocket maximum.

8 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means a participant’s total out-of-pocket maximum could contain a combination of coinsurance and/or copayments.

9 Includes medical and prescription drug copays, coinsurance and deductibles. Excludes non-network and bariatric services.

† Under the Affordable Care Act, certain preventive health and women’s services are paid at 100% (at no cost to the member) conditioned upon physician billing and diagnosis. In some cases, you may still be responsible for payment on some services. Some age requirements may apply.

This comparison chart offers a general overview of benefi ts and their associated out-of-pocket expenses under HealthSelect plans. Contact a Personal Health Assistant for specifi c questions. Call toll-free at (800) 252-8039, Monday-Friday 7 a.m. - 7 p.m. CT, or Saturday 7 a.m. - 3 p.m. CT to speak with a Personal Health Assistant.



HEALTH PLANS COMPARISON CHART




Benefi tsHealthSelectSM of Texas HealthSelect Out-of-State Consumer Directed HealthSelectSM

Network Non-Network Network Non-Network Network Non-Network


$1,500 per family1 None $500 per person1

$1,500 per family1

$2,100 per person1

$4,200 per family1

$4,200 per person1 $8,400 per family1





$7,000 per personper calendar year1 None None


$6,650 per person1 $13,300 per family1 None $6,650 per person1

$13,300 per family1 None **$6,650 per person1 $13,300 per family1 None

Primary care physician required Yes No No No No No

Primary care physicians’ offi ce visit $25 copay 40%* $25 copay 40%* 20%** 40%*

Mental health care


$25 copay 40%* 20% 40%* 20%** 40%*






20%** 40%*


20% 40%* 20% 40%* 20%** 40%*

Physicals# No charge 40%* No charge 40%* No charge 40%*

Specialty physicians’ offi ce visits $40 40%* $40 40%* 20%** 40%*


$40 40%* $40 40%* 20%** 40%*

Routine preventive care# No charge 40%* No charge 40%* No charge 40%*


20% 40%* 20% 40%* 20%** 40%*

Offi ce surgery and diagnostic procedures 20% 40%* 20% 40%* 20%** 40%*


$100 copay plus 20%


$100 copay plus 20%

$100 copay plus 40%* 20%** 40%*

Urgent care clinic $50 copay plus 20% 40%* $50 copay

plus 20% 40%* 20%** 40%*



HEALTH PLANS COMPARISON CHART

Benefi tsHealthSelectSM of Texas HealthSelect Out-of-State Consumer Directed HealthSelectSM

Network Non-Network Network Non-Network Network Non-Network

Maternity care doctor charges only#; inpatient hospital copays will apply


40%*


40%*

No charge for routine prenatal appointments 20%** for fi rst post-natal visit

40%*

Chiropractic care

a. Coinsurance 20%; $40 copay plus 20% with offi ce visit 40%* 20%; $40 copay plus

20% with offi ce visit 40%* 20%** 40%*

b. Maximum benefi t per visit $75 $75 $75 $75 $75 $75


30 30 30 30 30 30



$150/day copay plus 40%* ($750 copay max-up to 5 days per hospital stay, $2,250 copay maxper calendar year per person)


$150/day copay plus 40%* ($750 copay max-up to 5 days per hospital stay, $2,250 copay max per calendar year per person)

20%** 40%*



$150 plus 20% (if admitted copay will apply to hospital copay)


20%** 20%**12


$100 copay plus 20%


$100 copay plus 20%

$100 copay plus 40%* 20%** 40%*



Not covereda. Deductible $5,000 b. Coinsurance 20% c. Lifetime max $13,000

Not covered Not covered Not covered

Hearing aids Plan pays up to $1,000 per ear every three years (no deductible).

Plan pays up to $1,000 per ear every three years (after deductible is met).

Durable medical equipment9 20% 40%* 20% 40%* 20%** 40%*

Ambulance services (non-emergency)9 20% 20% 20% 20% 20%** 20%**

*Note: 40% coinsurance after you meet the annual out-of-network deductible **Note: 20% coinsurance after you meet the annual in-network deductible1 Applies to calendar year, January 1 - December 31. 2 Does not include copays. 3 Applies to plan year, September 1 - August 31. 4 Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a participant’s total network out-of-pocket maximum could contain a combination of coinsurance and/or copayments. 5 Includes medical and prescription drug copays, coinsurance and deductibles. Excludes non-network and bariatric services. 6 Copay depends on whether treatment is given by PCP or specialist. 7 Outpatient testing only. Does not apply to inpatient services. 8 No copay if high-tech radiology is performed during ER visit or inpatient admission.

9 Preauthorization required. 10 Active employees only; see health plan for additional requirements/limitations. 11 The deductible and coinsurance paid for bariatric surgery does not apply to the total out-of-pocket maximum. 12 Benefi ts shown do not apply to out-of-network freestanding ERs. For information about this coverage, see the Master Benefi t Plan Document. # Under the Affordable Care Act, certain preventive and women’s health services are paid at 100% (at no cost to the participant) dependent upon physician billing and diagnosis. In some cases, the participant will still be responsible for payment on some services.



Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail) 300 E. Randolph St. TTY/TDD: 855-661-6965 35th Floor Fax: 855-661-6960 Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: 800-368-1019 200 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to fi le a grievance.

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LANGUAGE ASSISTANCE

CONTACT INFORMATIONWe’re Here to HelpCustomer Service: Personal Health Assistants

BCBSTX Personal Health Assistants are trained to help you and your covered family members plan for better health care.

www.healthselectoftexas.com

Mental Health

Your medical plan offers mental health benefits to support your emotional and psychological well-being. Call a Personal Health Assistant toll-free at (800) 252-8039 if you have questions about your benefits or need help finding an in-network mental health provider.

Prescription Drugs

For information regarding prescription drug benefits for active employees, retirees not enrolled in Medicare, and their dependents, call the HealthSelect Prescription Drug Program at (855) 828-9834.

Blue Cross and Blue Shield of Texas is third-party administrator for the HealthSelectSM of Texas and Consumer Directed HealthSelectSM.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans

747986.0718

Call toll-free (800) 252-8039 Monday–Friday 7 a.m. - 7 p.m. CT and Saturday 7 a.m. - 3 p.m. CT

OR

Chat via Blue Access for Members or the BCBSTX Mobile App

Monday–Friday 8 a.m. - 5 p.m. CT

Documents

Call toll-free (800) 252-8039 Monday-Friday 7 a.m. - 7 p.m ......2019 Medical Benefits Guide 1 Call toll-free (800) 252-8039 Monday-Friday 7 a.m. - 7 p.m. central time (CT) and Saturday