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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 09/01/2021– 08/31/2022
The University of Texas System: PPO Plan Coverage for: Individual + Family | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-866-882-2034 or at
www.bcbstx.com/ut. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
For UT Health Network Provider:
$350 Individual/$1,050 Family
For In-Network:$350 Individual/$1,050 Family
For Out-of-Network:$750 Individual/$2,250 Family
Generally, you must pay all of the costs from providers up to the deductible amount
before this plan begins to pay. If you have other family members on the plan, each
family member must meet their own individual deductible until the total amount of
deductible expenses paid by all family members meets the overall family deductible.
Are there services
covered before you
meet your deductible?
Yes. Services that charge a copay, emergency
room services, certain preventive care, and
diagnostic test (x-ray, blood work) are covered
before you meet your overall deductible.
This plan covers some items and services even if you haven’t yet met the deductible
amount. But a copayment or coinsurance may apply. For example, this plan covers
certain preventive services without cost sharing and before you meet your
deductible. See a list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific
services?
Yes. Bariatric surgery deductible $3,000/person.
Prescription drug deductible $100/person. There
are no other specific deductibles.
You must pay all of the costs for these services up to the specific deductible amount
before this plan begins to pay for these services.
What is the out-of-
pocket limit for this
plan?
For UT Health Network Provider:
$8,550 Individual/$17,100 Family
For In-Network: $8,550 Individual/$17,100 Family
For Out-of-Network: Unlimited
The out-of-pocket limit is the most you could pay in a year for covered services. If
you have other family members in this plan, they have to meet their own
out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in
the out-of-pocket limit?
Premiums, bariatric deductible, balance-billing
charges, certain specialty drugs considered
non-essential health benefits, and healthcare this
plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket
limit.
Will you pay less if you
use a network provider?
Yes. See www.bcbstx.com/ut or call
1-866-882-2034 for a list of network providers.
You pay the least if you use a provider in UT Health Network Provider. You pay
more if you use a provider in-network. You will pay the most if you use an
out-of-network provider, and you might receive a bill from a provider for the
difference between the provider’s charge and what your plan pays (balance billing).
Be aware, your network provider might use an out-of-network provider for some
services (such as lab work). Check with your provider before you get services.
Do you need a referral to
see a specialist?
No.
You can see the specialist you choose without a referral.
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* For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/ut.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event
What You Will Pay
Limitations, Exceptions, & Other
Important Information
UT Health
Network Provider
(You will pay the
least)
In-Network
Provider
Out-of-Network
Provider
(You will pay the
most)
If you visit a health
care provider’s office
or clinic
$20 copay/visit;
deductible does
not apply
$30 copay/visit;
deductible does
not apply
40% coinsurance
Virtual visits are available, please refer
to your plan policy for more details.
$25 copay/visit;
deductible does
not apply
$35 copay/visit;
deductible does
not apply
40% coinsurance
None
No Charge;
deductible does
not apply
No Charge;
deductible does
not apply
40% coinsurance
You may have to pay for services that
aren’t preventive. Ask your provider if
the services needed are preventive.
Then check what your plan will pay for.
If you have a test
No Charge;
deductible does
not apply
No Charge;
deductible does
not apply
40% coinsurance
None
$100 copay;
deductible does
not apply
$100 copay;
deductible does
not apply
$100 copay plus
40% coinsurance
Copay is waived if the member calls
Health Advocate prior to service.
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* For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/ut.
Common
Medical Event
What You Will Pay
Limitations, Exceptions, & Other
Important Information
UT Health
Network Provider
(You will pay the
least)
In-Network
Provider
Out-of-Network
Provider
(You will pay the
most)
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available
at www.express-
scripts.com/ut
$10 (retail) $20
(mail/Smart90®)
copay
$10 (retail) $20
(mail/Smart90®)
copay
Reimbursement
based on
allowable amount
Copays are per prescription. Annual
deductible: $100 per person; 30-day
supply retail; 90-day supply mail or
Smart90®. Smart90® is a feature of
your prescription plan allowing a 90 day
fill at Walgreens locations and UT
pharmacies.
Specialty medications must be filled by
Accredo Specialty Pharmacy to allow in-
network copayments.
$35 (retail) $87.50
(mail/Smart90®)
copay
$35 (retail) $87.50
(mail/Smart90®)
copay
Same as above
$50 (retail) $125
(mail/Smart90®)co
pay
$50 (retail) $125
(mail/Smart90®)co
pay
Same as above
Same as above if
filled by Accredo or
a UT Specialty
pharmacy
Same as above if
filled by Accredo or
a UT Specialty
pharmacy
Same as above
If you have outpatient
surgery
$100 copay/
service then 10%
coinsurance
$100 copay/
service then 20%
coinsurance
40% coinsurance
Bariatric surgery is covered, subject to a
$3,000 per person deductible. Member
must be continuously enrolled in either
the UT SELECT or UT CONNECT plan
for 36 months prior to date of surgery.
10% coinsurance
20% coinsurance
40% coinsurance
None
If you need
immediate medical
attention
$150 copay/
service then 10%
coinsurance;
deductible does
not apply
$150 copay/
service then 20%
coinsurance;
deductible does
not apply
$150 copay/
service then 20%
coinsurance;
deductible does
not apply
Emergency room copay waived if
admitted.
20% coinsurance
20% coinsurance
20% coinsurance
Ground and air transportation covered.
$20/$25
copay/visit;
deductible does
not apply
$30/$35
copay/visit;
deductible does
not apply
40% coinsurance
Specialist has higher copay.
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* For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/ut.
Common
Medical Event
What You Will Pay
Limitations, Exceptions, & Other
Important Information
UT Health
Network Provider
(You will pay the
least)
In-Network
Provider
Out-of-Network
Provider
(You will pay the
most)
If you have a hospital
stay
10% coinsurance
$100 copay/day
then 20%
coinsurance
40% coinsurance
Preauthorization is required.
Max copay $500 per admission.
10% coinsurance
20% coinsurance
40% coinsurance
None
If you need mental
health, behavioral
health, or substance
abuse services
$20/$25
copay/office visit;
deductible does
not apply
10% coinsurance
for other outpatient
services
$30/$35
copay/office visit;
deductible does
not apply
20% coinsurance
for other outpatient
services
40% coinsurance
Specialist has higher copay.
Certain services must be preauthorized;
refer to your benefit booklet* for details.
Virtual visits are available, please refer
to your plan policy for more details.
10% coinsurance
$100 copay/day
then 20%
coinsurance
40% coinsurance
Preauthorization is required.
Max copay $500 per admission.
If you are pregnant
$20/$25 copay
initial visit;
deductible does
not apply
$30/$35 copay
initial visit;
deductible does
not apply
40% coinsurance
Specialist has higher copay.
Cost sharing does not apply for
preventive services. Depending on the
type of services, a copayment,
coinsurance, or deductible may apply.
Maternity care may include tests and
services described elsewhere in the
SBC (i.e. ultrasound.)
10% coinsurance
20% coinsurance
40% coinsurance
10% coinsurance
$100 copay/day
then 20%
coinsurance
40% coinsurance
Preauthorization is required.
Max copay $500 per admission.
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* For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/ut.
Common
Medical Event
What You Will Pay
Limitations, Exceptions, & Other
Important Information
UT Health
Network Provider
(You will pay the
least)
In-Network
Provider
Out-of-Network
Provider
(You will pay the
most)
If you need help
recovering or have
other special health
needs
10% coinsurance
20% coinsurance
40% coinsurance
Preauthorization is required.
Limited to 120 visits per plan year.
$20/$25
copay/visit;
deductible does
not apply
$30/$35
copay/visit;
deductible does
not apply
40% coinsurance
Limited to 35 days per condition per plan
year each if physical therapy modalities
or occupational therapy is billed. Limited
to 60 days per condition per plan year
for speech and hearing therapy.
$20/$25
copay/visit;
deductible does
not apply
$30/$35
copay/visit;
deductible does
not apply
40% coinsurance
10% coinsurance
20% coinsurance
40% coinsurance
Preauthorization is required.
Limited to 180 days per calendar year.
20% coinsurance
20% coinsurance
40% coinsurance
Preauthorization required for
wheelchairs and certain other durable
medical equipment over $5,000.
10% coinsurance
20% coinsurance
40% coinsurance
Preauthorization is required.
If your child needs
dental or eye care
Not Covered
Not Covered
Not Covered
None
Not Covered
Not Covered
Not Covered
None
Not Covered
Not Covered
Not Covered
None
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture
Cosmetic surgery (except specific conditions)
Dental care (Adult/Child, except when medically
necessary)
Infertility treatment (except diagnostic tests)
Long term care
Routine eye care (Adult/Child)
Routine foot care (except for the diagnosis of
diabetes)
Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Bariatric surgery (separate deductible applies;
predetermination recommended)
Chiropractic care
Hearing aids (36-month period max of $1,000/per
ear for hearing aid. Children 18 and under no
max applies)
Non-emergency care when traveling outside the
U.S. (www.bluecardworldwide.com)
Private-duty nursing (except inpatient private
duty nursing) limited to 90 visits per year
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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: the plan at 1-866-882-2034, U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/healthreform, or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323
x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance
Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com, or contact the U.S. Department of Labor's Employee Benefits Security
Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.
Contact the Texas Department of Insurance's Consumer Health Assistance Program at 1-800-252-3439 or visit www.texashealthoptions.com.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-866-882-2034.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-882-2034.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-866-882-2034.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-882-2034.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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The plan would be responsible for the other costs of these EXAMPLE covered services.
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)
Mia’s Simple Fracture
(in-network emergency room visit and follow
up care)
Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)
The plan’s overall deductible $350
Specialist copayment $35
Hospital (facility) coinsurance 10%
Other coinsurance 20%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles*
$400
Copayments
$300
Coinsurance
$2,100
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$2,860
The plan’s overall deductible $350
Specialist copayment $35
Hospital (facility) coinsurance 10%
Other coinsurance 20%
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles*
$450
Copayments
$900
Coinsurance
$90
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is
$1,460
The plan’s overall deductible $350
Specialist copayment $35
Hospital (facility) coinsurance 10%
Other coinsurance 20%
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles
$400
Copayments
$500
Coinsurance
$300
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$1,200
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
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The plan would be responsible for the other costs of these EXAMPLE covered services.
*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?” row above.
.
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language assistance.
We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)
300 E. Randolph St. TTY/TDD: 855-661-6965
35th Floor Fax: 855-661-6960
Chicago, Illinois 60601 Email: [email protected]
You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:
U.S. Dept. of Health & Human Services Phone: 800-368-1019
200 Independence Avenue SW TTY/TDD: 800-537-7697
Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html