SelecTEMP^® PPO

Policy Form Number: PPO-STM-3

How does SelecTEMP PPO work?

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 charges for the rest of the benefit period up to $2,000,000 per participant.

When does SelecTEMP PPO coverage begin?

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*.

*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.

The following conditions MUST be met before SelecTEMP PPO coverage can begin:

• You are a resident of Texas; and
• 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;

Need additional coverage?

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.

Extension of Benefits

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:

• date the participant is no longer Totally Disabled, or
• payment of maximum benefits, or
• end of 90 days

Payment Options:

• Blue Cross and Blue Shield of Texas can accept the first premium payment by automated bank draft, credit card or check.
• Upon underwriting and approval, subsequent monthly premiums can be paid by automated bank draft. Blue Cross and Blue Shield of Texas cannot accept a credit card for subsequent monthly premium payments.
• Once established, customer cannot cancel bank draft until selected benefit period is expired.