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Office Setting Services
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If using network providers Select Blue Advantage, a preferred provider health benefit insurance plan, pays:
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Physician Services
Allergy Injections (billed with the office visit)*, **
Allergy Tests
Consultation
Dental Exam (within the first 48 hours after an accident)
Hearing Exam Office Visit Charge**
Injections (except allergy injections), if billed as injections only
Office Visit
Routine Immunizations (age 8 and over)**
Routine Physical Exam Office Visit**
Vision Exam**
Well-baby Exam**
Well-woman exam** (including pap smear if filed before $300 annual max is exhausted)
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100% of the allowable amount after copay
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Immunizations
(birth through age 7)
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100% of allowable amount
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Diagnostic Tests
Lab – Office
X-Ray – Office
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100% of allowable amount after copay
if performed on the same day and ordered by a network provider
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Other Benefits
Certain Outpatient Procedures
Office Surgery
Physical / Occupational Therapy**
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Coinsurance after deductible
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*When billed separately, medical / surgical coinsurance applies plus any applicable deductible.
**Subject to days or dollar maximums.
Note: Services requiring a return office visit, for example, lab/X-ray, on a different day will require a new copayment.
* Texas Department of Insurance Form: PPO-SELBLUE-ADV-3-OLC-2
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