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Company Information

Preventive Care

Office Setting Services	If using network providers PPO Select Choice pays
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 eight (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)	100 percent of allowable amount after copay
Immunizations (birth through age seven (7))	100 percent of allowable amount
Diagnostic Tests Lab – Office X-Ray – Office	80 percent of allowable amount after deductible
Other Benefits Certain Outpatient Procedures Office Surgery Physical/Occupational Therapy	Coinsurance after deductible

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
© Copyright 2012. Health Care Service Corporation. All Rights Reserved.

Important Information about Blue MedicareRx^SM

^SM Service Mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

^® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

Blue Cross and Blue Shield of Texas refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services.

A stand-alone prescription drug plan with a Medicare contract.

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