| General Benefits |
| In-Network Benefits |
Out-of-Network Benefits |
| Select Blue Advantage Series III, a Preferred Provider Health Insurance Plan, pays 85 percent and you pay 15 percent of the allowable amount after you meet your deductible. |
Select Blue Advantage Series III, a Preferred Provider Health Insurance Plan pays 75 percent and you pay 25 percent of the allowable amount after you meet your deductible. |
| $25 office visit copay includes same day lab and X-ray, up to annual max of $750. |
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-SELBLUE-ADV-3-OLC-2
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