The UT SELECT Medical plan through Blue Cross and Blue Shield (BCBS) of Texas provides access to one of the largest networks of contracting doctors and hospitals in Texas. There are more than 45,000 contracting physicians and specialists and over 400 contracting hospitals in Texas alone. If you are traveling outside of Texas, there are even more BCBS Network providers from which to choose. In fact, more than 85 percent of all doctors and hospitals throughout the United States contract with BCBS. If you use a network physician or hospital throughout the United States, your benefits will be the same robust benefits you enjoy in Texas or if you reside outside of Texas, the benefits you enjoy as an out-of-area participant.
To find a network physician or specialist near you, search online at www.bcbstx.com/ut or contact BCBS of Texas Customer Service toll free at 1-866-882-2034.
To assist you in summarizing your network, out-of-network and out-of-area benefits, you may review the Benefits Summary Chart.
When you travel abroad, always carry your UT SELECT Medical Identification Card which has the telephone number to the BlueCard Worldwide® program and contains important information about your plan. With BlueCard Worldwide®, you have access to a large number of hospitals on almost every continent and to a broad range of medical assistance services.
BlueCard Worldwide® provides the following services to UT SELECT Medical Participants:
Call BlueCard® Access toll free at 1-800-810-BLUE (2583) or call collect at (804) 673-1177, 24 hours a day, seven days a week to locate a participating physician or hospital. In some instances participating physicians or hospitals will submit your claim on your behalf. You may also contact your Institution Benefits Office or download and print the Benefits Summary Chart for benefit details.
As an international traveler, additional services are available through the UT System-wide International SOS program. International SOS is a comprehensive, 24-hour medical and emergency response organization that works on your behalf to coordinate with your insurance provider in the United States and providers abroad to ensure that you receive the assistance you need.
Membership benefits through International SOS are available at no cost when traveling abroad on University business and are available at a discount for traveling companions and employees traveling abroad for leisure.
Information and a quick reference to the International SOS program and the UT SELECT Medical plan can be found on the Foreign Coverage Quick Reference Sheet.
International drug claims are submitted and processed in the same manner as domestic claims received from a non-network pharmacy. After you purchase your prescription while traveling internationally, you should submit a claim form and receipt. Be sure to include all the member and patient information, including your Benefits Identification Number, along with the drug information, currency used and country of purchase. Once the claim is received by Express Scripts, the claim will be entered into the system and subject to eligibility and edits, including drug coverage and plan design. The National Drug Code used by Express Scripts is specific to foreign claims, and prices at 100% of the amount submitted (converted to United States dollars). Express Scripts will then apply a reduction in the reimbursement by the appropriate copayment. To calculate the converted value, Express Scripts uses the services of a financial web site which provides the exchange rate in effect when the prescription was filled.
Due to FDA regulations, Express Scripts Home Delivery is unable to ship prescription medication internationally. Be sure you have an adequate supply of medication to take with you. You may also call Express Scripts Customer Service at 1-800-818-0155 to request a Vacation Override and receive an extended supply of medication prior to departure.
For the UT SELECT Dental and UT SELECT Dental Plus plans, Delta Dental provides the same level of dental benefits while traveling in the United States or Internationally. Members may be required to pay out-of-pocket for services and submit a copy of the receipt to Delta Dental to receive a refund. For questions, please call Delta Dental Customer Service at 800-893-3582.
The DeltaCare USA plan is limited to emergencies outside of Texas and the United States unless you are seeking routine care from your Primary Care Dentist within Texas. For assistance, please call 800-443-2995.
|Dental Service||UT SELECT Dental||UT SELECT Dental Plus||DeltaCare|
|International||Delta Dental provides the same level of dental benefits while traveling in the United States or Internationally. Members may be required to pay out of pocket for services and submit a copy of receipt to Delta Dental to receive a refund.||The DeltaCare Plan is limited to emergencies outside of the United States or when care is received from a provider that is not your Primary Care Dentist.|
|Service Area||Available Nationwide and Puerto Rico, non-network providers are available internationally|
|Maximum Annual Benefit||$1,250||$3,000|
|Annual Deductible||$25 per Person||None|
|Oral Exam, X-rays, Cleaning||$0||$0|
|Fluoride Treatment||$0, up to age 19||$0, up to age 19|
|Sealants||$0, up to age 14||$0, up to age 14|
|Space Maintainers||$0, up to age 14||$0, up to age 14|
|Fillings||add 20% up to maximum allowed by plan||Fully paid by plan|
|Extractions||add 20% up to maximum allowed by plan||Fully paid by plan|
|Root Canals||add 20% up to maximum allowed by plan||Fully paid by plan|
|Periodontics||add 20% up to maximum allowed by plan||Fully paid by plan|
|Crowns, Jackets and Cast Restorations||add 50% up to maximum allowed by plan||add 20% up to maximum allowed by plan|
|Bridges and Dentures||add 50% up to maximum allowed by plan||add 20% up to maximum allowed by plan|
|Orthodontics||50%, $1,250 Lifetime benefit per person||add 20% up to maximum allowed by plan, $3,000 Lifetime benefit per person|
|Claim Form Mailing Address||Delta Dental Insurance Company
P.O. Box 1809
Alpharetta, GA 30023-1809
|Delta Dental Insurance Company
P.O. Box 1809
Alpharetta, GA 30023-1809
|DeltaCare USA Claims
P.O. Box 1810
Alpharetta, GA 30023-1810
Superior Vision and Superior Vision Plus will provide coverage for eligible out-of-country services and products on an “out-of-network” basis only. In case you have a need to replace glasses, lenses, or contacts while you travel, we recommend you take a copy of your vision prescription with you when traveling. You will pay the provider in full at the time of service and submit an itemized invoice or receipt to Superior Vision. Reimbursement is based on the foreign currency exchange rate at the time of service. Reimbursement is in equivalent United States dollars only. Reimbursement will be mailed to the address you list on the claim form. For assistance, please contact Superior Vision Customer Service at (800) 507-3800.