Page 11 - Impact Floors 2022 Benefit Guide

In-Network Medical

Claims Examples

PCP Sick Visit Core HDHP Plan Middle Plan Buy-Up Plan
Billed Amount $250 $250 $250

Allowable Amount $70.35 $70.35 $70.35
Member Pays $70.35 $35 $30

Preferred Brand Rx Core HDHP Plan Middle Plan Buy-Up Plan
Billed Amount $70 $70 $70

Allowable Amount $35.67 $35.67 $35.67
Member Pays $35.67 $50 $50

Knee Surgery Core HDHP Plan Middle Plan Buy-Up Plan
Billed Amount $30,000 $30,000 $30,000

Allowable Amount $15,000 $15,000 $15,000
Impact Floors HSA Contribution $750.00 $0 $0
Member Pays $5,250 $8,150 $5,500

Find a Network Provider

To search for a provider within the BCBSTX Blue Choice PPO network:
 Go to www.bcbstx.com
 Click on “Find a Doctor or Hospital”
 Under “Not a Member Yet?”, click on “Search a Guest”
 Click on “Search All Providers”
 Enter your provider name, your zip code, network, specialty, etc.
 Click on “Find a doctor or hospital” to view your search results
 Please search using the Blue Choice PPO network

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