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Preventive Care

Office Setting Services

If using network providers PPO Select Value Care pays

Physician Services

Routine Physical Examinations
Well-child Care
Hemoccult Tests
Pap Smears
Immunizations 8-years-old and over
Routine lab
X-ray
Annual Routine Vision and Hearing Exams
(Routine mammograms, colorectal cancer screening and prostate cancer screenings are not subject to the $300 maximum)

50 percent of allowable amount

$300 Calendar Year Maximum per participant

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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