SelecTEMP PPO. Area Listings and Rates

Transcription

1 SelecTEMP PPO Area Listings and Rates Rates Effective December 1, 2012

2 SelecTEMP PPO How to Calculate Rates Area Listings and Rates Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Determine the number of months of coverage you need. If the policy will last 6 months or fewer, use the charts for 1 and 6 Months. If the policy will last longer, use the charts for 7 and 11 Months for each month s premium. Determine your area based on the first three digits of your ZIP code from the ZIP code area listing below. Select the rate column that corresponds to your chosen deductible ($500, $1,000, $1,500, $2,000 or $2,500) and gender, then use the rate in the row corresponding to your age and repeat for your spouse, if applicable. Find the appropriate child(ren) rate by checking the deductible and selecting: 1 child, 2 children or 3 or more children.* Add the rates for you, your spouse, if applicable, and your child(ren), if applicable. Multiply the total from Step 5 by the number of months of coverage you need. This is the total premium for the coverage period selected. Applicant s Rate Spouse s Rate Child(ren) s Rate Total Monthly Rate $ + $ + $ = $ Coverage Period (1 to 11 months) months Total Premium Due Make your check payable to: Blue Cross and Blue Shield of Texas = $ Note: s are per person, per benefit period. There is no deductible credit or carry over from one contract to another. Important Step 8 The total premium must be submitted with the application unless you have chosen the Monthly Bank Draft option. The Monthly Bank Draft option is available to the applicant who selects a 2- to 11-month coverage period. A check for the first month of premium must accompany the application along with the Bank Draft Authorization Request Form. * Children applying without a parent or guardian must submit one application per child. ZIP Code Area Listing Area 1 788, 798, 799, 885 Area 2 759, , , 785, 790 Area 3 733, 757, 758, 760, 761, 763, , 774, 775, 778, 783, 784, 786, 787, 789, 791, 792, Area 4 751, 755, 756, 773, 776, 777, 793, 794 Area 5 750, , 762, 779

3 1 and 6 Months for Area 1 ZIP Codes: 788, 798, 799, Child Children Children

4 7 and 11 Months for Area 1 ZIP Codes: 788, 798, 799, Child Children Children ,

5 1 and 6 Months for Area 2 ZIP Codes: 759, , , 785, Child Children Children

6 7 and 11 Months for Area 2 ZIP Codes: 759, , , 785, Child Children Children ,

7 1 and 6 Months for Area 3 ZIP Codes: 733, 757, 758, 760, 761, 763, , 774, 775, 778, 783, 784, 786, 787, 789, 791, 792, Child Children Children

8 7 and 11 Months for Area 3 ZIP Codes: 733, 757, 758, 760, 761, 763, , 774, 775, 778, 783, 784, 786, 787, 789, 791, 792, Child Children Children , , ,

9 1 and 6 Months for Area 4 ZIP Codes: 751, 755, 756, 773, 776, 777, 793, Child Children Children ,

10 7 and 11 Months for Area 4 ZIP Codes: 751, 755, 756, 773, 776, 777, 793, Child Children Children , , ,338 1,

11 1 and 6 Months for Area 5 ZIP Codes: 750, , 762, Child Children Children ,

12 7 and 11 Months for Area 5 ZIP Codes: 750, , 762, Child Children Children , , ,352 1,

13 Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Registered Service Mark of Health Care Service Corporation A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association