BlueCross BlueShield of Texas
Gold Health Plans
All Blue Advantage Gold HMO Plans offer the same set of essential health benefits, quality and amount of care as the Blue Advantage Silver and Gold HMO Plans. The Blue Advantage Gold HMO Plans are the most expensive plans, but also have the most comprehensive benefits. Gold Plans have a higher monthly premium and often lower out-of-pocket costs than Silver and Bronze plans.
Blue Advantage Gold HMO Plans may be right for you if you are an individual or family who:
- Are willing to have a primary care physician (PCP) coordinate your care
- Prefers fixed doctor visit copayments
- Are expecting to have surgery or major services in the near future and want the lowest out of pocket costs
- Requires regular prescription medication
- Do NOT have an HSA (Gold plans are not HSA compatible)
There are deductibles for this plan, and this is an HMO plan. You must select a Blue Advantage HMO Primary Care Physician (PCP) when enrolling in this plan.
While Gold plans offer the highest level of coverage, there are no PPO options available in Texas, so members that have doctors outside the network should opt for the Blue Advantage Plus Gold 101 which will have some out-of-network benefits; but make sure to talk to your doctor and BCBSTX to confirm the availability of these benefits.
The Best Gold Plan
This HSA Eligible plan has a lower deductible and OOP max, meaning you can save for the expenses you do incur and still have a higher level of pretection in the event of unexpected health costs. The Blue Advantage Plus plans also offer some out of network benefits even though this is still technically an HMO, so if your doctor isn’t in any individual plan network for 2017, this is likely your best option.
|Plan Name||Blue Advantage Gold HMO 101||Blue Advantage Gold HMO 111*||Blue Advantage Plus Gold 101|
|Summary of Benefits||View Full Details||View Full Details||View Full Details|
|Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.||$500||$0||$2,750|
|CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max||30%||0%||20%|
|Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (includes deductible)||$5,250||$7,150||$3,500|
|Primary Care Office Visit||$20||$50||$10|
|Specialist Office Visit||$40||$75||$20|
|Mental Illness Treatment and Substance Abuse Rehab Office Visit||$20||$50||$10|
|Emergency Room||$500 per occurrence copay, then 30%||$750||$400 per occurrence copay, then 20%|
|Inpatient Hospital Service||$300 per occurrence copay, then 30%||$1,500||$200 per occurrence copay, then 20%|
|Outpatient Surgery||$200 per occurrence copay, then 50%||$500||$200 per occurrence copay, then 40%|
|Outpatient X-Rays and Diagnostic Imaging||50%||$100||40%|
|Outpatient Imaging (CT/PET Scans/MRIs)||50%||$250||40%|
|Network||Blue Advantage HMO|
|Outpatient Prescription Drugs – Preferred Pharmacy||$0/$10/$50/$100/30%||$0/$10/$50/$100/30%||$0/$10/$50/$100/30%|
|Outpatient Prescription Drugs – Non-Preferred Pharmacy||$5/$15/$60/$110/30%||$5/$15/$60/$110/30%||$5/$15/$60/$110/30%|
|Prescription Drug Utilization Benefit Management Programs||Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider. Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSTX and you may first need to try more clinically appropriate or cost-effective drugs. Mail-Order Program: You may receive up to a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit.|
*Not available on the health exchange marketplace (not subsidy eligible)
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Popular Hospital Network Guide
|Hospital||Included in Advantage HMO Network?|
|Doctors Hospital At Renaissance (Edinburg)||YES|
|University Health System (San Antonio)||NO|
|Medical City Hospital (Dallas)||YES|
|Memorial Hermann Hospital (Sugar Land)||YES|
|Mother Frances Hospital (Tyler)||NO|
|Scott & White Hospital (Round Rock)||NO|
|North Austin Medical Center (Austin)||YES|
|Seton Medical Center (Austin)||YES|
|Hill Country Memorial Hospital (Fredericksburg)||YES|
|Texas Health Harris Methodist (Fort Worth)||YES|
|UT Southwestern Medical Center (Dallas)||NO|
|Memorial Hermann Texas Medical Center (Houston)||YES|
|St. Lukes Episcopal Hospital (Houston)||YES|
|Baylor University Medical Center (Dallas)||YES|
|The Methodist Hospital (Houston)||YES|
BCBSTX Dental Plans
With the BCBSTX dental plan, you’ll get dental coverage on day one with no deductible deductible required for check-ups, cleanings and other preventive services. Most important, costs are typically reduced when you receive care from any of our participating network dentists. However, you also have the option to see any dentist not in the network, but your out-of-pocket costs may be higher.
Some highlights of Dental Indemnity USA coverage:
- Coverage can be used to provide dental benefits to an individual, spouse, children or any combination of dependents.
- A $50 deductible, based on fee schedule allowances, applies for dental procedures or services received by a covered individual during each benefit year.
- Maximum deductible amount of $150 for family coverage.
- Deductibles do not apply to oral exams, cleanings, fluoride treatments, sealants and X-rays.
- $1,000 orthodontia benefit for children under 19 years old
For more information on coverage and benefits, view the Dental Outline of Coverage
You must enroll in a BCBSTX health plan in order to enroll in the dental plan (you have up to 31 days from the effective date of your policy to enroll). Shop for a plan now.
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