This information is intended for Employees and Retirees Under Age 65 residing in Texas.
The following is an example of your out-of-pocket costs for physician charges for emergency room treatment. Physician charges can include charges from the performing provider, anesthesiologist, pathologist, radiologist, neonatologist and emergency room physician. Please note that this is only an example as billed and allowable amounts may differ.
For an example of hospital charges in addition to the physician charges, please review Emergency Room Treatment (Hospital or Facility Charges).
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Download your benefits book for a complete description of your benefits
If you have any additional questions, please contact BCBSTX Customer Service at (800) 252-8039. Review other examples of out-of-pocket costs
All services are paid based on the BCBSTX allowable amount. If you use any providers who do not contract with BCBSTX, you will be responsible for charges above the BCBSTX Allowable Amount.
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Network |
Non-Network (with ParPlan providers) |
Non-Network (with non-contracting providers) |
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Billed Amount |
$350 |
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Allowable Amount |
$130 |
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HealthSelect Pays |
$104 |
If you have not met any of your $500 calendar year non-network deductible: HealthSelect pays $0 |
If you have not met any of your $500 calendar year non-network deductible: HealthSelect pays $0 |
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If you have met your entire $500 calendar year non-network deductible: HealthSelect pays $78 |
If you have met your entire $500 calendar year non-network deductible: HealthSelect pays $78 |
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You Pay |
You pay a total of $26 |
If you have not met any of your $500 calendar year non-network deductible: You pay a total of $130 |
If you have not met any of your $500 calendar year non-network deductible: You pay $130 deductible plus the difference of billed and allowable amount. You Pay $350 |
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If you have met your entire $500 calendar year non-network deductible: You pay a total of $52 |
If you have met your entire $500 calendar year non-network deductible: You pay $52 coinsurance plus the difference of billed and allowable amount. You Pay $272 |
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