A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
PPO Features
A&M Care Plan
• Administered by Blue Cross and Blue Shield of Texas (BCBSTX)
• No primary care physician (PCP) required; no referrals required to see
a specialist
• Select any provider for care within the PPO network or outside the
network
• When you receive care inside the network
– Highest level of benefits
– No claims to file
– No balance billing for amounts over the BCBSTX allowed amount
• When you receive care outside the network
– May have to file own claims
– Receive lower level of benefits and can be balanced billed
• Worldwide coverage for emergency and non-emergency care
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What’s New?
Effective 9/1/2014 for A&M Care Plan
Coinsurance
Copays
CHANGE FROM
CHANGE TO
Plan pays 70%
You pay 30%
Plan pays 80%
You pay 20%
DO NOT apply to the
out-of-pocket maximum
DO apply to the
out-of-pocket maximum
No benefits changes for the 65+ Plan
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More Hospitals and Doctors
For a current listing of all providers
see our website at:
bcbstx.com
Offers names, addresses, map and
directions.
For World Wide Assistance
Call 1-800-810-BLUE (2583)
Or Collect 1-804-673-1177
In-network coverage is available when
traveling or living worldwide
Available
24 Hours a Day, Seven Days a Week
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Your BlueChoice PPO Benefits
MEMBER SHARE
BENEFITS
A&M Care In-Network /
Out-of-Network Plan
65+ Plan
$700 / $1,400
$500
Deductible – Family
$2,100 / $4,200
–
Out-of-Pocket Maximum – Individual
$5,000 / $10,000
$1,400
Out-of-Pocket Maximum – Family
$10,000 / $20,000
–
$30/$45 per visit /
50% after deductible
20% after deductible
100% covered / Not covered
100% paid after deductible
20% after deductible /
50% after deductible
20% after deductible
Deductible – Individual
Office Visit (primary care / specialist)
Most Lab and X-ray paid at 100%
Preventive Services
Inpatient Hospital
Emergency Room
20% after deductible /
20% after deductible
(50% after deductible for
non-emergency)
20% after deductible
20% after deductible
Chiropractic – 30 visits per plan year
$45 per visit /
50% after deductible
20% after deductible
Maternity Care – Doctor
$30 initial visit only /
50% after deductible
20% after deductible
Diagnostic Procedures/MRIs and PET scans
20% after deductible /
50% after deductible
20% after deductible
All other covered services
20% after deductible/
50% after deductible
Retirees over age 65 are not eligible for copays, your benefits are secondary to Medicare
20% after deductible
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Preventive Coverage
Stay Healthy by Getting Regular Check-ups
What’s covered?
Recommended routine gender- and
age-specific preventive care, such as annual
physical, OB/GYN exams, mammograms and
other cancer screenings, well-child care and
immunizations – both facility and professional
services
Preventive coverage provided in-network
at 100% with no copay, no deductible
Get an annual
physical and reduce
your monthly
premium!
Remember: Lab tests related to an illness or condition
are not considered preventive and may pay differently
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Retiree Information
Retirees under age 65
Are considered Network and can use the Network providers
Retirees over age 65
Choose from:
Remember:
• A&M Care Plan
• Enroll in BOTH Medicare
• 65 Plus – you must be:
• When you receive your
– Age 65 and enrolled in Medicare Parts A&B
or disabled under 65 and enrolled in Medicare
Parts A&B
– Working for the A&M System, if at all, less
than 50% time or for less than 4.5 months
during the plan year
– If covering a spouse, spouse must be age 65
or older (or disabled) and enrolled in Medicare
Parts A&B
parts A & B.
Medicare Card, notify
BCBSTX and your Human
Resource Office of your
Medicare number which
includes an alpha
character.
• If you use a Provider that
accepts Medicare or is a
BCBSTX provider, you
cannot be balance billed.
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Retiree Coordination of Benefits
Example
A&M CARE PLAN
(deductible not met)
A&M CARE PLAN
(deductible is met)
Charge
$500
$500
Medicare paid 80%
$400
$400
Patient Share 20%
$100
$100
A&M Care Plan Deductible
$700
MET
Applied to Deductible
$500
Zero
BCBSTX Would Have Paid
Zero
$350
A&M Care Plan Payment
Zero
$100
Patient’s Responsibility
$100
Zero
Plans calculate the normal plan benefits, then pay that amount,
or the difference after Medicare has paid, whichever is less.
Your coinsurance will continue until you meet the out-of-pocket maximum, then plan pays at 100%.
A&M Care 65 Plus = $1,400
A&M Care Plan = $5,000 individual/$10,000 Family
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Benefits Value Advisor
Same procedure, lower cost1
• Now you can speak to a BCBSTX Benefits Value Advisor who helps
you find quality providers for health care services such as:
– Imaging services (X-rays/MRIs/CT scans)
– Maternity services
– Joint replacement surgery
– Back surgery
• Benefits Value Advisors can also help you
plan for your health care by:
– Helping you understand your benefits
– Finding in-network providers
– Scheduling visits
– Requesting preauthorization
– Helping you access online
educational tools
1. Benefits Value Advisors offer cost estimates for various providers, facilities and procedures.
Lower pricing and cost savings are dependent on the provider or facility of your choosing.
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Benefits Value Advisor
Cost comparison for an MRI at two different providers:
PROVIDER A – KNEE MRI
PROVIDER B – KNEE MRI
$374*
$2,573*
Costs can vary by $2,000 for the same procedure depending on where you go!*
One call can result in big savings!
Just call the number on the back of your member ID card to reach a
Benefits Value Advisor.
*Example cost data from Tarrant county.
Member communications and information from Benefits Value Advisors are not meant to replace the advice of health care professionals. Members are encouraged to seek
the advice of their doctors to discuss their health care needs. Decisions regarding course and place of treatment remain with the member and his or her health care
providers. Cost estimates are just an estimate. In addition to your usual deductibles, copayments and/or coinsurance, the actual cost of the services may vary based on a
number of factors including the date of service, the actual procedure performed and what services were billed by the provider and your particular benefit plan. Coverage is
subject to the limitations and exclusions of your plan.
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Condition Management
If you have a chronic
condition, we offer support
Blue Care® Advisors – clinical professionals – can
help you manage chronic health conditions such as:
Asthma, coronary disease, diabetes, COPD or
low back pain
• Understand and follow your physician’s orders
• Review medications, side effects, compliance, refills and current
services
• Establish goals with caregivers, scheduling follow-ups as
appropriate
If you are identified as being at risk or having one
of the managed chronic conditions, one of our
Blue Care Advisors will contact you.
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Lifestyle Management Support
Tobacco Cessation and
Weight Management
Programs
Other Resources
• Counseling and coaching with
licensed Wellness Coaches
• Personal telephone coaching
• 24/7 Nurseline
• Secure email outreach
• Well onTarget®
• Self-paced online courses
• Blue 365®
• Tobacco cessation
resources
• Referrals when appropriate
• Weight management
resources
• Jenny Craig®
• Life Time Fitness®
• Proctor & Gamble Dental Products
• Vision Plans
• And more…
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24/7 Nurseline
Around-the-Clock Advice
and Information by Phone
1-800-581-0368
• 24/7 access to registered nurses for
health conditions such as:
‒ High fevers
‒ Earaches
‒ Cuts and bruises
• 1,200 audio health library topics
• Referral of members with care needs to
the appropriate program
• Follow-up calls for emergency care
needs
• Available in English and Spanish
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A New Way to Experience Wellness
Access Well onTarget by logging in to
Blue Access for Members and get support
to make healthy choices
o Health Assessment (HA)
o Self-Paced Courses
o Trackers
o Food and Exercise Diary
o Health and Wellness Content
o Fitness Program
o Complementary and Alternative Medicine
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Making wellness simpler, more affordable and more accessible for members
Vision Care and
Eyewear– Discounts on
eyewear, contact lenses and laser
vision correction surgery
Hearing Aids – Discounts on
hearing aids for members, parents
and grandparents
Dental Products – Discounts
on Procter & Gamble oral care
bundles
Life Time®´ Fitness –
Enrollment fee will be waived for
new members who join one of the
Life Time Fitness clubs nationwide
Weight Management –
Discounts at Jenny Craig®´
on membership and food
Under the My Coverage tab
And more
Register online at
blue365deals.com/BCBSTX/
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SM
Blue Access for MEMBERS
Save time with self-service support tools and health and
wellness resources on a convenient and secure online site
• Check claims and claims history
• View, save or print Explanation of Benefits (EOBs)
• Sign up for electronic EOBs, and turn off paper
• View benefits and covered dependents
• Check coverage details
• Manage mobile and texting preferences
• Request new ID cards or print temporary
ID cards
• Access health and wellness information
and guides
• Get details on wellness, discounts
… and more
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Blue Access Homepage
My Coverage shows who’s
covered on your plan, YTD
spending for each family
member, cost estimator,
deductible discounts and ID card
request. From My Coverage
page, click on Incentives, then
Visit Site to view completed
activities so you can make sure
that your Wellness Exam
Incentive has been recorded.
My Claim Activity
displays recent
claims, or go to the
Claims Center for
all your claim details
Access Provider
Finder® to locate
doctors, specialists,
facilities, directions
and Blue Distinction
Centers®
My Health tab links
you to health and
wellness content,
articles, videos, and
My Care Profile
Quick Links for
easy access to
Health Assessment,
Fitness Program,
Member Discounts,
or to get an ID card
Form Finder easier
to view and find
specific forms for
members
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Health Assessment
Powerful Health and Wellness Tool
User-friendly health assessment tool
• Personal Health Assessment designed
to be completed in 10 to 15 minutes
• Choose your assessment topic, such
as health and wellbeing or fitness
and physical activity
• All topics must be completed to receive
credit
Know Your Risks
bcbstx.com
Complete all topics under the HA and receive
a $50 deductible credit for members and
dependents ages 18 and over
Manage Your Health
Examines the member’s
overall health and
wellbeing and provides
a personalized report
showing areas where
you can improve
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Blue Access Mobile Overview
SM
Current Mobile Offerings
•
•
•
•
Mobile Web (public)
Blue Access for MembersSM (secure)
Text Messaging (static and dynamic)
Provider Finder® App (iPhone and Android)
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Provider Finder® puts you in charge
Use Provider Finder to:
o Find a network primary care physician, specialist or
hospital
o Search results by doctor, specialty, ZIP code, language
and gender – even get directions from Google Maps™
o Estimate the cost of a provider’s procedures,
treatments and tests
o Determine if a Blue Distinction Center for Specialty
Care® is an option for treatment
o View patient feedback or add your review for a provider
o View quality, certifications and recognitions for doctors
bcbstx.com
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What if I Have Questions
Personalized Service 8 am – 8 pm
• Our Philosophy – “Take the Member
Out of the Middle”
• Call your dedicated customer service
team for:
‒ Benefit information
‒ Network provider information
‒ Membership and eligibility
‒ Inquiries (telephone and email)
‒ ID card requests
‒ Claims inquiries
‒ Help with online tools
866-295-1212
Toll-free
Customer Service
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Your ID Card
Need Assistance?
Call the Customer Service
number on the back of the
ID card to:
• Ask about benefits and
claims
• Talk to a Benefits Value
Advisor (BVA) to locate
facilities for MRIs, CTs,
maternity services,
hip/knee/spine surgeries,
and more
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