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Company Information

General Benefits

In-Network Benefits	Out-Of-Network Benefits
Preferred Provider Health Insurance Plan (PPO) Select^® Saver Series III pays 75 percent and policyholder pays 25 percent of covered expenses after the deductible has been met.	Preferred Provider Health Insurance Plan (PPO) Select^® Saver Series III pays 60 percent and the policyholder pays 40 percent of covered expenses after the deductible has been met.
All physician office visits will be subject to deductible and coinsurance.	All physician office visits will be subject to deductible and coinsurance.
Network providers will precertify medical care.	Policyholders must precertify hospital admissions and certain services.
There are usually no claim forms to file.	Policyholders may have to submit claims for reimbursement.
Emergency room visits within 24 hours of accident subject to deductible and coinsurance - 75/25.	Emergency room visits within 24 hours of accident subject to deductible and coinsurance - 75/25.

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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