HEALTHSELECT OUT-OF-STATE BENEFITS AT A GLANCEAn overview of your medical benefits.www.healthselectoftexas.com

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

2 www.healthselectoftexas.com

HEALTHSELECT OUT-OF-STATE

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 (In-Area)

• You no longer 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 Blue Cross and Blue Shield of Texas (BCBSTX) toll-free at (800) 252-8039 to move your dependent to

HealthSelect Out-of-State.

Why you may still want to have a PCP

Even 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.

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BENEFITS CHARTH

ealthSelect Out-of-State

Benefits1HealthSelectSM of Texas Out-of-State2

In-Network Out-of-Network

Calendar year deductible None$500 per person

$1,500 per family

Out-of-pocket coinsurance maximum3

$2,000 per person per calendar year

$7,000 per person per calendar year

Total out-of-pocket maximum4 (including deductibles, coinsurance and copays)5

$6,550 per person

$13,100 per familyNone

Primary care physician required No No

Primary care physicians’ office visits $25 40%*

Physicals† No charge 40%*

Specialty physicians’ office visits $40 40%*

Routine eye exam, one per year per participant6 $40 40%*

Routine preventive care† No charge 40%*

Diagnostic x-rays, lab tests, and mammography 20% coinsurance 40%*

Office surgery and diagnostic procedures 20% coinsurance 40%*

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

$100 copay plus 20% coinsurance

$100 copay plus 40%*

Urgent care clinic$50 copay plus 20% coinsurance

40%*

Maternity Care doctor charges only†; inpatient hospital copays will apply

No charge for routine prenatal appointments

$25 or $40 for first prenatal visit10

40%*

Chiropractic Care

a. Coinsurance$40 copay with office visit plus 20% coinsurance

40%*

b. Maximum benefit 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% coinsurance ($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)

Benefits1HealthSelectSM of Texas Out-of-State2

In-Network Out-of-Network

Emergency care11

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

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

Outpatient surgery other than in physician’s office

$100 copay plus 20% coinsurance

$100 copay plus 40%*

Bariatric surgery12

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

Not covered

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

Durable medical equipment9 20% coinsurance 40%*

Ambulance services (non-emergency)9 20% coinsurance 40%*

Mental health care

a. Outpatient physician or mental health provider office visits

$25 copay 40%*

b. Hospital Mental health inpatient stay

$150/day copay plus 20% coinsurance ($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)

20% coinsurance 40%*

* Note: 40% coinsurance after you meet the annual out-of-network deductible. 1 Benefits 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 HealthSelect Out-of-State applies to employees and retirees under age 65 and their eligible dependents who live or work outside of Texas. You cannot enroll in Out-of-State coverage unless your work or home address is outside of Texas.

3 Does not include copays.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 For treatment charges, one visit per plan year.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 Copay depends on whether treatment is given by PCP or specialist11 Benefits shown do not apply to out-of-network freestanding ERs. For information about

this coverage, see the Master Benefit Plan Document.12 Active employees only; see health plan for additional requirements/limitations. The

deductible and coinsurance paid for bariatric surgery does not apply to the total out-of-pocket maximum.

† 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.

This comparison chart offers a general overview of benefits and their associated out-of-pocket expenses under HealthSelect plans. Contact a Personal Health Assistant for specific 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.

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

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 746164.0917

CONTACT INFORMATION

We’re Here to HelpCustomer Service: Personal Health Assistants

Blue Cross and Blue Shield of Texas’ Personal Health Assistants are trained to

help you and your covered family members plan for better health care.

Call toll-free (800) 252-8039

Monday–Friday 7 a.m. - 7 p.m. CT and Saturday 7 a.m. - 3 p.m. CT

24/7 Nurseline

If you’re not sure where to go for care or you just have questions, calling the

24/7 Nurseline may help you. With the 24/7 Nurseline, you and your covered

family members have access to caring registered nurses at any time, any day

of the year. Call toll-free (800) 581-0368.

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

and their dependents, call the HealthSelect Prescription Drug Program at

(855) 828-9834.

Send claims and correspondence, including claim appeals, to:

Blue Cross and Blue Shield of Texas

PO Box 660044

Dallas, TX 75266-0044

www.healthselectoftexas.com