Blue Cross Blue Shield of Texas

Products
Group
HMO Blue Texas
BlueCard PPO
BlueChoice PPO
Small Group (2-50)
Individual
Select Blue Advantage Series III
PPO Select^® Choice Series III
PPO Select^® Saver Series III
BlueEdge^SM Individual HSA
PPO Select Value^® Care^SM
PPO Select Basic^SM
Foundation Hospital Care
SelecTEMP^® PPO
Dental Indemnity USA

General Benefits

In-Network Benefits	Out-Of-Network Benefits
Foundation Hospital Care pays 80 percent and you pay 20 percent of covered expenses after you meet your calendar year deductible.	Foundation Hospital Care pays 60 percent and you pay 40 percent of covered expenses after you meet your calendar year deductible.
Emergency Room visit is subject to a $200 copayment amount and calendar year deductible, then pays 80 percent and you pay 20 percent.	Emergency Room visit is subject to a $200 copayment amount and calendar year deductible, then pays 80 percent and you pay 20 percent.

* Texas Department of Insurance Form: PPO-In Hospital-OLC-1