Plan Highlights
Select Blue Advantage Provides:

Affordable, cost effective health coverage
Freedom to choose doctors and hospitals
Choice of deductibles
Choice of out of pocket security provisions
Three-tier prescription drug program
Individual, spouse and child(ren) coverages available
24-hour, worldwide emergency care
BlueCard PPO benefits coinsurance
Prescription Drug Card
Lifetime max is $2 million per person
Organ/tissue transplant - $300,000 lifetime per person

Options	Calendar Year Deductibles				Copayment Amounts		Calendar Year Out-of-Pocket Maximum/Security Provisions				Coinsurance
	Individual In-Network	Individual Out-of-Network	Family In-Network	Family Out-of-Network	Office Visit (Includes lab and x-ray)*	Emergency Care (Facility Only)	Individual In-Network	Individual Out-of-Network	Family In-Network	Family Out-of-Network	In-Network		Out-of-Network
											Plan Pays	You Pay	Plan Pays	You Pay
Plan I	$250	$500	$750	$1,500	$30	$75	$2,000	$3,000	$4,000	$6,000	85%	15%	75%	25%
Plan II	$500	$1,000	$1,500	$3,000
Plan III	$1,000	$2,000	$3,000	$6,000	$35	$75	$3,000	$5,000	$6,000	$10,000
Plan IV	$1,500	$3,000	$4,500	$9,000
Plan V	$2,500	$5,000	$7,500	$15,000	$45	$75	$5,000	$8,000	$10,000	$16,000
Plan VI	$5,000	$10,000	$15,000	$30,000
All other medical-surgical expense (lab and x-ray) will be subject to deductible and coinsurance amounts 85% subject to the deductible *Percentage apply to covered expenses after calendar year deductibles are met

In-Network Benefits Out-of-Network Benefits

Select Blue Advantage pays 85% and you pay 15% of covered expenses after you meet your deductible Select Blue Advantage pays 75% and you pay 25% of covered expenses after you meet your deductible

$30, $35 or $45 office visit copay (depending on Plan selected) includes some lab and x-ray Physician office visits subject to deductible and coinsurance

Network providers will precertify your medical care You must precertify hospital admissions and certain services

No claim forms to file You may have to submit claims for reimbursement

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Copyright 2002 Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* HMO plans offered by Southwest Texas HMO, Inc.* d/b/a HMO Blue Texas * Independent Licensees of the Blue Cross and Blue Shield Association