Plan Highlights
PPO Select® Choice Provides:

Affordable, cost effective health coverage
Freedom to choose doctors and hospitals
Choice of deductibles
Choice of out of pocket security provisions
Prescription Drug Card
Individual, spouse and child(ren) coverages available
24-Hour, Worldwide Care
Well Child Care through age 7 including immunization
Human Organ Transplant Benefits - $300,000 limit
Prescription Drug Card
Lifetime max is $2 million 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 (Physician consultation only)	Emergency Care*	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	$25	80%	$3,000	$5,000	$6,000	$10,000	80%	20%	75%	25%
Plan II	$500	$1,000	$1,500	$3,000
Plan III	$1,000	$2,000	$3,000	$6,000	$25	80%	$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	$25	80%	$3,000	$5,000	$6,000	$10,000
Plan VI	$5,000	$10,000	$15,000	$30,000
80% subject to the deductible *Percentages apply to covered expenses after calendar year deductibles are met

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
General Benefits

In-Network Benefits Out-of-Network Benefits

PPO Select® Choice pays 80% and you pay 20% of covered expenses after you meet your deductible PPO Select® Choice pays 75% and you pay 25% of covered expenses after you meet your deductible

$25 office visit copay (physician consultation only) 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