SelecTEMP^® PPO is individual health coverage that provides you, your spouse and your children essential, basic protection against unexpected accidents or illnesses. SelecTEMP PPO offers various benefit periods and deductibles to give you the control to tailor coverage, premium rates and out-of-pocket expenses according to your own needs. SelecTEMP PPO is the affordable temporary health insurance plan from Blue Cross and Blue Shield of Texas.

Choose 1, 2, 3, 4, 5 or 6 months of benefit coverage and a $500, $1,000, $1,500, $2,000 or $2,500 deductible, depending on your needs.

You pay the selected benefit period deductible. Once the deductible is met, SelecTEMP PPO will pay 80% of the next $5,000 on in-network eligible expenses. You pay 20% of in-network eligible expenses, up to $1,000. Then SelecTEMP PPO pays 100% of eligible expenses for the rest of the benefit period up to $2,000,000 per participant.

How it Works
The plan design includes three tiers of medications. The three tiers are comprised of:
· Generic drugs
· Preferred brand-name drugs
· Non-preferred brand-name drugs

Mail Order Prescription Drug Program
You may obtain up to a 90-day supply of your covered prescription drug for two copay amounts.

To help with your prescription choices, check the drug list and prescribing guidelines section of the Blue Cross and Blue Shield of Texas Web site.

Provider Access and Networks
The SelecTEMP PPO program provides individuals and their families with easy and affordable access to doctors and hospitals.

With SelecTEMP PPO — you will have:
· Freedom to choose doctors and hospitals when you need health care
· Access to our BlueChoice^® Solutions network
· 24-hour worldwide coverage
· BlueCard Program

To view the BlueChoice Solutions network, you may access Provider Finder.

BlueChoice^® Solutions
Access to Any Doctor, Any Time
When you choose a PPO — preferred provider organization — you can receive care from any licensed doctor you want. If you want to use a BlueChoice^® Solutions network doctor, you’ll pay less out-of-pocket, you usually won’t have to file any claims and you’ll get the highest level of benefits. If you use a doctor outside of the network, you’ll still be covered, but your out-of-pocket costs will be higher.

BlueChoice Solutions Network
When you choose the SelecTEMP PPO plan, you have access to the BlueChoice Solutions network, a subset of one of the largest networks of contracting doctors and hospitals in Texas, containing on average, approximately 70 percent of the doctors (varies by region) and all the facilities that are in the larger BlueChoice network. You also have access to the BlueCard network, one of the largest networks in the country, with doctors and hospitals contracting with Blue Cross and Blue Shield Plans nationwide.

Out-of-Network Alternatives Can Still Save You Time and Money
Chances are the doctors and hospitals you want to use are in the network. If your doctor is not in the network, you can always continue your care for covered services and pay a higher out-of-pocket cost. If you don’t go to a BlueChoice Solutions network doctor, your out-of-pocket costs will be higher, but visiting a ParPlan doctor can still help you save time and money. They will usually file claims for you, and they won’t balance bill you for charges that exceed the allowable amounts — a cost-saving feature that’s not available with all carriers.

BlueCard Network Providers
Through the BlueCard PPO Program, Blue Cross and Blue Shield (BCBS) Plans work together to help ensure customers receive quality, affordable health care. BCBS Plans throughout the country have established Preferred Provider Organization (PPO) networks of doctors, hospitals and other health care providers. These extensive provider networks are available to 97 percent of the U.S. population.

· Texas residents at least 60 days of age and under 65 years of age
· Anyone not currently pregnant
· Applicants not anticipating adding newborns or child(ren) to the contract except if required by court order
· Unmarried dependent children at least 60 days of age and under 25 years of age
· U.S. citizen or a non-U.S. citizen living in the United States for at least two years. A copy of your Alien Registration Receipt Card (Green Card) must be submitted with your application.

You can select coverage for yourself, your spouse and children under a single contract; or a spouse-only or child-only contract can be issued.

The Benefit Period begins on the later of:
A) The requested effective date; or
B) The day after the postmark date affixed by the U.S. Post Office.^*
The following conditions MUST be met before SelecTEMP PPO coverage can begin:
· You are a resident of Texas
· You answered “NO” to all the Health Questions on the SelecTEMP PPO application
· Your completed application and premium are received by Blue Cross and Blue Shield of Texas within 10 days of the signature date.

Example: If you choose a three-month coverage period and request an effective date of September 5, coverage will begin at 12:01 a.m. on the 5th and expire at 11:59 p.m. on December 4.

Note: If coverage begins on the 31st day of the month, it will end the last day of any shorter expiration month, if applicable (e.g., January 31 to April 30).

* If the envelope containing the application is not postmarked by the U.S. Post Office, or if the postmark is not legible, the effective date will be the later of: a) the requested effective date; or b) the date received by Blue Cross and Blue Shield of Texas.

After your deductible is met, your coverage pays 80% of the allowable amount for the following in-network eligible expenses:

Inpatient Hospital Expense
· Preauthorized hospital admission, room and board charges for semiprivate room
· Intensive care and coronary care units
· All other usual hospital services

Medical-Surgical Expenses include but are not limited to:
· Services of physicians or other professional providers
· Physical medicine services (therapies) up to a maximum benefit of $500 per participant per benefit period
· Diagnostic X-ray, laboratory procedures and radiation therapy
· Rental of durable medical equipment
· Professional local ground or air ambulance service up to a maximum benefit of $750 per participant per benefit period
· Anesthetic and its administration
· Oxygen and its administration
· Blood, blood plasma and blood plasma expanders
· Prosthetic appliances
· Orthopedic braces and crutches
· Home infusion therapy
· Diabetic supplies and equipment
· Certain tests for detection of prostate cancer
· Childhood immunizations through age 7 at 100% of allowable amount
· Outpatient contraceptive devices and services
· Certain tests for detection of colorectal cancer
· Prescription drugs and medicines (not used in a hospital) up to a maximum benefit of $750 per participant per benefit period, subject to separate drug deductible and copay

This Summary of Benefits provides a brief description of some of the important features of your SelecTEMP PPO Contract. This is not the insurance contract, and only the actual contract provisions will control. The contract itself provides in detail the rights and obligations of you, your physician and Blue Cross and Blue Shield of Texas. It is important that you read your contract carefully! If your application is submitted by an agent or broker, the agent or broker must hold a valid Group 1 license and be appointed to do business with Blue Cross and Blue Shield of Texas.

Preauthorization is required for all hospital admissions, extended care expense and home infusion therapy. Preauthorization helps to assure you are receiving appropriate and medically necessary care. You or your physician or a family member should call the toll-free number listed on the back of your ID card.

Failure to preauthorize will result in a $250 penalty for any hospital admission.

If you need coverage for an additional period of time, you may apply for a second non-renewable SelecTEMP PPO contract. Any condition which may have existed or occurred under the prior contract will be a preexisting condition under the subsequent contract and will not be covered.

If you are totally disabled on the expiration date of this contract, covered benefits will continue to be payable for any continuous illness or injury that began while this contract was in force and will continue during the continuous total disability of the participant until the earliest of:

1. Date the participant is no longer totally disabled
2. Payment of maximum benefits
3. End of 90 days.

If you are interested in applying for permanent individual coverage, look at long term plans.

· Complete the application in blue or black ink.
· Determine your premium by using the rate worksheet on the back of the application.
· If you are not a U.S. citizen but have been a permanent resident for the past two years, you can apply for coverage. You MUST submit a copy of your Alien Registration Receipt Card or Green Card along with the completed application and your premium.

· If paying by the Single Payment Plan, make your check payable to Blue Cross and Blue Shield of Texas and mail it with the application in the envelope provided. If you are selecting a one-month benefit period, you must select the Single Payment Plan.
· If paying by the Monthly Bank Draft, make your check payable to Blue Cross and Blue Shield of Texas for the first month of premium, complete the bank draft authorization request form, and submit a blank check marked VOID with your application in the envelope provided. The Monthly Bank Draft option is available for 2 to 6-month benefit periods.
· Once established, a member cannot cancel bank draft until the selected benefit period is expired.
· SelecTEMP PPO premiums are non-refundable.

Please refer to Outline of Coverage for additional information.

Or call us at (866) INSU-BUY or (972) 985-4400.