| General Benefits |
| In-Network Benefits |
Out-of-Network Benefits |
| PPO Select® Choice Series III, a Preferred Provider Health Insurance Plan, pays 80 percent and you pay 20 percent of the allowable amount after you meet your deductible. |
PPO Select® Choice Series III, a Preferred Provider Health Insurance Plan, pays 70 percent and you pay 30 percent of the allowable amount after you meet your deductible. |
| $25 office visit copay (physician consultation only). |
Physician office visits subject to deductible and coinsurance. |
| Network providers will usually precertify your medical care. |
You must precertify hospital admissions and certain services. |
| There are usually no claim forms to file. |
You may have to submit claims for reimbursement. |
* Texas Department of Insurance Form: PPO-SELCHOICE-3-OLC-2
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