BCBSTX 2018 Plan Guide

Blue Cross Blue Shield of Texas

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BlueCross BlueShield of Texas is the largest health insurance company in the state with over 5 million members in all 254 Texas counties. BCBSTX offers health plans that can be customized for individuals, children, and families that include consumer-directed plans, Health Savings Accounts, and Medicare Supplements.

BCBSTX no longer offers PPOs on the individual market; however, Advantage Plus plans offer the added option of using providers other than Blue Advantage network providers, while still having some of the costs covered.

BCBSTX 2018 Plans

Blue Cross Gold 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

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.

Bronze Blue Advantage Bronze HMO Blue Advantage Plus Bronze
204 – Two $40 PCP Visits 201
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.  $5,600 $2,850
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max 50% 40%
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)2 $7,350 $6,550
Primary Care Office Visit First 2 PCP visits $40, then 50% 40%
Specialist Office Visit 50% 40%
Mental Illness Treatment and Substance Abuse Rehabilitation Office Visit  

50%

 

40%

Emergency Room $950 per occurrence deductible, then 50% $950 per occurrence deductible, then 40%
Urgent Care $60 copay 40%
Inpatient Hospital Services $850 per occurrence deductible, then 50% $850 per occurrence deductible, then 40%
Outpatient Surgery4 $600 per occurrence deductible, then 50% $600 per occurrence deductible, then 40%
Outpatient X-Rays and Diagnostic Imaging4 50% 40%
Outpatient Imaging (CT/PET Scans/MRIs)4 50% 40%
Network Blue Advantage HMO Blue Advantage Plus HMO
HSA Eligible5 No Yes
Outpatient Prescription Drugs – Preferred Pharmacy 6 7 $10/$20/30%/35%/45%/50% 20%/25%/30%/35%/45%/50%
Outpatient Prescription Drugs – Non-Preferred Pharmacy 6 7 $20/$30/35%/40%/45%/50% 25%/30%/35%/40%/45%/50%
Prescription Drug Utilization Benefit Management Programs8 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 meet certain criteria or try more cost-effective drugs.

Mail-Order Program: You may receive a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit.

 

  1. Depending on your plan, benefits are either reduced or not available when non-participating providers are used. This is a summary of benefit highlights only. All benefits shown indicate member responsibility.
  2. The standard deductible and out-of-pocket maximum for this plan are shown. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Note that copays apply whether or not you have met the deductible.
  3. All percentages shown are of the allowable amount for covered services.
  4. Members may have lower out-of-pocket costs for some services provided by non-emergency freestanding outpatient facilities than the out-of-pocket costs for services provided in a hospital setting. See your Summary of Benefits and Coverage for additional details.
  5. As a reminder, a Health Savings Account (HSA) has tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax adviser regarding tax consequences of specific health insurance plans or products.
  6. Prescription benefit coverage starts after annual medical deductible has been met, not counting copays.
  7. Six prescription drug payment level tiers: Preferred Generics / Non-Preferred Generics / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty.
  8. Mail order is not available for Preferred and Non-Preferred Specialty tier drugs. These tiers are limited to a 30-day supply. Coverage limitations may apply to certain medications.

Blue Cross Silver Plans

BCBSTX Silver plans offer a higher level of coverage than Bronze plans, and those who purchase on-exchange may also be eligible for cost-sharing reductions based on income, lowering deductibles and co-pays. Silver plans are ideal for people who have regular medications or utilize specialist or doctors visits more often than their included yearly check-up.  Silver plans are a good “middle of the road” option for people who might need to utilize their healthcare options more but may not be able to afford higher premium payments.

Blue Advantage Silver HMO Blue Advantage Silver HMO Blue Advantage Silver HMO Blue Advantage Plus Silver
Plan Number 102 103 107 102 – Three $0 PCP Visits
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.2 $3,000 $3,750 $3,500 $3,250
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max 30% None (Member pays 0% after deductible) 20% 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)2 $7,150 $3,750 $7,150 $6,850
Primary Care Office Visit $40 100% after deductible $30 First three visits $0, then 20%
Specialist Office Visit $60 100% after deductible $65 20%4
Mental Illness Treatment and Substance Abuse Rehab Office Visit $40 40%4 $30 $0
Emergency Room $600 per occurence copay, then 30%4 40%4 $400 copay after deductible $600 per occurence copay, then 20%
Urgent Care $40 100% after deductible $75 $20
Inpatient Hospital Services $500 per occurence copay, then 30%4 100% after deductible 20%4 $400 per occurence copay, then 20%
Outpatient Surgery5 $300 per occurence copay, then 50%4 100% after deductible 20%4 $300 per occurence copay, then 40%
Outpatient X-Rays and Diagnostic Imaging5 50%4 100% after deductible 20%4 40%
Outpatient Imaging (CT/PET Scans/MRIs)5 30%4 100% after deductible 20%4 40%
Network Blue Advantage HMOSM Blue Advantage HMO
HSA Eligible6 No Yes No No
Outpatient Prescription Drugs – Preferred Pharmacy7 8 $0/$10/$50/$100/30% No member share3 $15/$15/$50/$100/40% $0/$10/$50/$100/30%
Outpatient Prescription Drugs – Non-Preferred Pharmacy7 8 $5/$15/$60/$110/30% No member share3 $15/$15/$50/$100/40% $5/$15/$60/$110/30%

Blue Cross Bronze Plans

BlueCross BlueShield of Texas Bronze plans are ideal for individuals looking for low-cost plans. Bronze plans have higher out of pocket costs, but two plans (the 106 and 104) also have HSA options for those looking for tax savings. These plans are ideal for those who do not have regular medications or visit the doctor outside of their yearly check-up (included as preventative care on all plans.)

Bronze Blue Advantage Bronze HMO Blue Advantage Plus Bronze
204 – Two $40 PCP Visits 201
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.  $5,600 $2,850
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max 50% 40%3
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)2 $7,350 $6,550
Primary Care Office Visit First 2 PCP visits $40, then 50% 40%3
Specialist Office Visit 50%3 40%3
Mental Illness Treatment and Substance Abuse Rehabilitation Office Visit  

50%3

 

40%3

Emergency Room $950 per occurrence deductible, then 50% $950 per occurrence deductible, then 40%
Urgent Care $60 copay 40%3
Inpatient Hospital Services $850 per occurrence deductible, then 50% $850 per occurrence deductible, then 40%
Outpatient Surgery4 $600 per occurrence deductible, then 50% $600 per occurrence deductible, then 40%
Outpatient X-Rays and Diagnostic Imaging4 50%3 40%3
Outpatient Imaging (CT/PET Scans/MRIs)4 50%3 40%3
Network Blue Advantage HMOSM Blue Advantage HMOSM
HSA Eligible5 No Yes
Outpatient Prescription Drugs – Preferred Pharmacy 6 7 $10/$20/30%/35%/45%/50% 20%/25%/30%/35%/45%/50%
Outpatient Prescription Drugs – Non-Preferred Pharmacy 6 7 $20/$30/35%/40%/45%/50% 25%/30%/35%/40%/45%/50%
Prescription Drug Utilization Benefit Management Programs8 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 meet certain criteria or try more cost-effective drugs.

Mail-Order Program: You may receive a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit.

 

  1. Depending on your plan, benefits are either reduced or not available when non-participating providers are used. This is a summary of benefit highlights only. All benefits shown indicate member responsibility.
  2. The standard deductible and out-of-pocket maximum for this plan are shown. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Note that copays apply whether or not you have met the deductible.
  3. All percentages shown are of the allowable amount for covered services.
  4. Members may have lower out-of-pocket costs for some services provided by non-emergency freestanding outpatient facilities than the out-of-pocket costs for services provided in a hospital setting. See your Summary of Benefits and Coverage for additional details.
  5. As a reminder, a Health Savings Account (HSA) has tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax adviser regarding tax consequences of specific health insurance plans or products.
  6. Prescription benefit coverage starts after annual medical deductible has been met, not counting copays.
  7. Six prescription drug payment level tiers: Preferred Generics / Non-Preferred Generics / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty.
  8. Mail order is not available for Preferred and Non-Preferred Specialty tier drugs. These tiers are limited to a 30-day supply. Coverage limitations may apply to certain medications.

Multi-State Plans

The Multi-State Plan (MSP) Program, established under the Affordable Care Act, directs the Federal Office of Personnel Management  to contract with private health insurers in each State to offer high-quality, affordable health insurance options called Multi-State Plans. There are no major differences between multi-state plans and other plans, and it does NOT mean these plans provide out of state benefits, just that benefits meet minimum requirements from state to state. Always check the doctor’s networks for each individual plans, and remember that emergency care is covered within the continental US.

BCBSTX appears to have discontinued Multi-State plans for 2018. 

HSA Plans

Health Savings Accounts can reduce your out of pocket costs as well as your tax burden. BCBSTX offers one of 3 HSA plans in Texas for 2018. Learn more at our HSA Guide.

Blue Cross And Blue Shield Of Texas · Blue Advantage Plus Bronze℠ 201
Bronze HMO| Plan ID: 33602TX0770108
Deductible
$2,850 Individual
Out-of-pocket maximum
$6,550Individual Total
Copayments / Coinsurance
Emergency room care: $950 Copay with deductible/40% Coinsurance after deductible
Generic drugs: 20% Coinsurance after deductible
Primary doctor: 40% Coinsurance after deductible
Specialist doctor: 40% Coinsurance after deductible
DOCUMENTS
Summary of Benefits
Plan brochure
Costs for medical care
Deductible
$2,850 Individual Total
Out-of-pocket maximum
$6,550 Individual Total
Primary care doctor visit
In Network Tier 1: 40% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: 50% Coinsurance after deductible
Specialist visit
In Network Tier 1: 40% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: 50% Coinsurance after deductible
X-rays and diagnostic imaging
Limits and exclusions apply: X-rays and diagnostic imaging
In Network Tier 1: 30% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: 50% Coinsurance after deductible
Laboratory outpatient and professional services
Limits and exclusions apply: Laboratory outpatient and professional services
In Network Tier 1: 30% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: 50% Coinsurance after deductible
Outpatient facility
Limits and exclusions apply: Outpatient facility
In Network Tier 1: $600 Copay with deductible/30% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: $1500 Copay with deductible/50% Coinsurance after deductible
Outpatient professional services
In Network Tier 1: $200 Copay with deductible/40% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: 50% Coinsurance after deductible
Hearing aids
Limits and exclusions apply: Hearing aids
In Network Tier 1: 40% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: 50% Coinsurance after deductible
Routine eye exam for adults
In Network: Benefit Not Covered
Routine eye exam for children
Limits and exclusions apply: Routine eye exam for children
In Network Tier 1: No Charge
In Network Tier 2: Not Applicable
Out of Network: Benefit Not Covered
Eyeglasses for children
Limits and exclusions apply: Eyeglasses for children
In Network Tier 1: No Charge After Deductible
In Network Tier 2: Not Applicable
Out of Network: Benefit Not Covered
Eligible for Health Savings Account (HSA)Yes Prescription drug coverage
Generic drugs
Limits and exclusions apply: Generic drugs
In Network Tier 1: 20% Coinsurance after deductible
In Network Tier 2: 25% Coinsurance after deductible
Out of Network: 50% Coinsurance after deductible
Preferred brand drugs
Limits and exclusions apply: Preferred brand drugs
In Network Tier 1: 30% Coinsurance after deductible
In Network Tier 2: 35% Coinsurance after deductible
Out of Network: 50% Coinsurance after deductible
Non-preferred brand drugs
Limits and exclusions apply: Non-preferred brand drugs
In Network Tier 1: 35% Coinsurance after deductible
In Network Tier 2: 40% Coinsurance after deductible
Out of Network: 50% Coinsurance after deductible
Specialty drugs
Limits and exclusions apply: Specialty drugs
In Network Tier 1: 45% Coinsurance after deductible
In Network Tier 2: 45% Coinsurance after deductible
Out of Network: 45% Coinsurance after deductible
Emergency room care
Limits and exclusions apply: Emergency room care
In Network Tier 1: $950 Copay with deductible/40% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: $950 Copay with deductible/40% Coinsurance after deductible
Inpatient doctor and surgical services
In Network Tier 1: 40% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: 50% Coinsurance after deductible
Inpatient hospital services (like a hospital stay)
Limits and exclusions apply: Inpatient hospital services (like a hospital stay)
In Network Tier 1: $850 Copay per Stay with deductible/40% Coinsurance after deductible
In Network Tier 2: Not Applicable
Out of Network: $1500 Copay per Stay with deductible/50% Coinsurance after deductible
Plan Brochures

Links to Summaries of Benefits & Coverage (SBC), Benefit Highlights and Plan Comparison Charts

for all Blue Cross and Blue Shield of Texas (BCBSTX) qualified health plans in the under 65 retail market.

 

PLAN Comparison Charts

COMPARISON CHART Link to Charts
BCBSTX Gold Plan Comparison Chart EnglishSpanish
BCBSTX Silver Plan Comparison Chart EnglishSpanish
BCBSTX Bronze Plan Comparison Chart EnglishSpanish

 

GOLD Plans

 

PLAN NAME

 

Plan Variance

Marketplace or Non Marketplace* Link to SBC Document Link to Benefit Highlights
Blue Advantage Plus Gold HMO 203 Standard Non Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Gold HMO 203 Standard Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Gold HMO 203 Native American Zero Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Gold HMO 203 Native American Limited Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Gold HMO 206 – Three $30 PCP Visits Standard Non Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Gold HMO 206 – Three $30 PCP Visits Standard Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Gold HMO 206 Native American Zero Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Gold HMO 206 – Three $30 PCP Visits Native American Limited Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Gold HMO 207 Standard Non Marketplace Summary of Benefits Benefit Highlights

SILVER Plans

 

PLAN NAME

 

Plan Variance

Marketplace or Non Marketplace* Link to SBC Document Link to Benefit Highlights
Blue Advantage Plus Silver HMO 202 Standard Non Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Silver HMO 202 Standard Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Silver HMO 202 Native American Zero Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Silver HMO 202 Native American Limited Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Silver HMO 202 73% Actuarial Value (AV) Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Silver HMO 202 87% Actuarial Value (AV) Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Silver HMO 202 94% Actuarial Value (AV) Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Silver HMO 205 – Two $25 PCP Visits Standard Non Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Silver HMO 205 – Two $25 PCP Visits Standard Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Silver HMO 205 Native American Zero Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Silver HMO 205 – Two $25 PCP Visits Native American Limited Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Silver HMO 205 – Two $25 PCP Visits 73% Actuarial Value (AV) Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Silver HMO 205 – Two $15 PCP Visits 87% Actuarial Value (AV) Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Silver HMO 205 – Two $5 PCP Visits 94% Actuarial Value (AV) Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Silver HMO 102 – Three $0 PCP Visits  

Standard

 

Non Marketplace

 

Summary of Benefits

 

Benefit Highlights

BRONZE Plans

 

PLAN NAME

 

Plan Variance

Marketplace or Non Marketplace* Link to SBC Document Link to Benefit Highlights
Blue Advantage Plus Bronze HMO 201 Standard Non Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Bronze HMO 201 Standard Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Bronze HMO 201 Native American Zero Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Plus Bronze HMO 201 Native American Limited Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Bronze HMO 204 – Two $40 PCP Visits Standard Non Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Bronze HMO 204 – Two $40 PCP Visits Standard Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Bronze HMO 204 Native American Zero Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Bronze HMO 204 – Two $40 PCP Visits Native American Limited Marketplace Summary of Benefits Benefit Highlights

 

CATASTROPHIC Plans

 

PLAN NAME

 

Plan Variance

Marketplace or Non Marketplace* Link to SBC Document Link to Benefit Highlights
Blue Advantage Security HMO 200 Standard Non Marketplace Summary of Benefits Benefit Highlights
Blue Advantage Security HMO 200 Standard Marketplace Summary of Benefits Benefit Highlights
Contact Us

Phone: (312) 726-6565
Email: help@ihealthagents.com

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

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2017 Plans

Blue Cross Gold 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

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.

Plan Name Blue Advantage Gold HMO 101 Blue Advantage Gold HMO 111* Blue Advantage Plus Gold 101
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%
Urgent Care $20 $50 $10
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
HSA Eligible No No No
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)

Blue Cross Silver Plans

BlueCross BlueShield Silver plans offer a higher level of coverage than Bronze plans, and those who purchase on-exchange may also be eligible for cost-sharing reductions based on income, lowering deductibles and co-pays. Silver plans are ideal for people who have regular medications or utilize specialist or doctors visits more often than their included yearly check-up.  Silver plans are a good “middle of the road” option for people who might need to utilize their healthcare options more but may not be able to afford higher premium payments.

Plan Name Blue Advantage Silver HMO 102 Blue Advantage Silver HMO 103 Advantage Silver HMO 107 Blue Advantage Plus Silver 102 (Three $0 PCP Visits)
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. $3,000 $3,750 3,500 $3,250
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max 30% 0% 20% 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) $7,150 $3,750 $7,150 $6,850
Primary Care Office Visit $40 $30 100% after deductible First three visits $0, then 20%
Specialist Office Visit $60 100% after deductible $65 20%
Mental Illness Treatment and Substance Abuse Rehab Office Visit $40 40% $30 $0
Emergency Room $600 per occurrence copay, then 30% 40% $400 copay after deductible $600 per occurrence copay, then 20%
Urgent Care $40 100% after deductible 100% after deductible $20
Inpatient Hospital Service $500 per occurrence copay, then 30% 100% after deductible 20% $400 per occurrence copay, then 40%
Outpatient Surgery $300 per occurrence copay, then 50% 100% after deductible $20% $300 per occurrence copay, then 40%
Outpatient X-Rays and Diagnostic Imaging 50% $100 40% $2,750
Outpatient Imaging (CT/PET Scans/MRIs) 30% 100% after deductible 20% 40%
Network Blue Advantage HMO
HSA Eligible No Yes No No
Outpatient Prescription Drugs – Preferred Pharmacy $0/$10/$50/$100/30% 100% after deductible $15/$15/$50/$100/40% $0/$10/$50/$100/30%
Outpatient Prescription Drugs – Non-Preferred Pharmacy $5/$15/$60/$110/30% 100% after deductible $15/$15/$50/$100/40% $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.

Blue Cross Bronze Plans

BlueCross BlueShield of Texas Bronze plans are ideal for individuals looking for low-cost plans. Bronze plans have higher out of pocket costs, but two plans (the 106 and 104) also have HSA options for those looking for tax savings. These plans are ideal for those who do not have regular medications or visit the doctor outside of their yearly check-up (included as preventative care on all plans.)

Plan Name Blue Advantage Bronze HMO 006 Blue Advantage Bronze HMO 105 Blue Advantage Plus Bronze 103 Blue Advantage Plus Bronze 104
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. $6,500 $6,850 $6,600 $5,000
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max None (Member pays 0% after deductible) 30% 20% 40%
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) $6,500 $7,150 $7,150 $6,550
Primary Care Office Visit 0% after deductible First 2 visits $40, then 30% First visit $0, then 20% 40%
Specialist Office Visit 0% after deductible 30% 20% 40%
Mental Illness Treatment and Substance Abuse Rehab Office Visit 0% after deductible $0 $0 40%
Emergency Room 0% after deductible 30% $950 per occurrence copay, then 20% 40%
Urgent Care 0% after deductible $40 100% after deductible $20
Inpatient Hospital Service 0% after deductible 30% $750 per occurrence copay, then 20% 40%
Outpatient Surgery 0% after deductible 50% $400 per occurrence copay, then 40% 50%
Outpatient X-Rays and Diagnostic Imaging 0% after deductible 50% $80 per occurrence copay, then 40% 50%
Outpatient Imaging (CT/PET Scans/MRIs) 0% after deductible 50% $600 per occurrence copay, then 40% 50%
Network Blue Advantage HMO
HSA Eligible Yes No No Yes
Outpatient Prescription Drugs – Preferred Pharmacy 0% after deductible 20%/20%/30%/40%/50% $15/30%/40%/45%/50% 30%/30%/40%/50%/50%
Outpatient Prescription Drugs – Non-Preferred Pharmacy 0% after deductible 25%/25%/40%/50%/50% $20/35%/50%/50%/50% 35%/35%/50%/50%/50%
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.

Multi-State Plans

The Multi-State Plan (MSP) Program, established under the Affordable Care Act, directs the Federal Office of Personnel Management  to contract with private health insurers in each State to offer high-quality, affordable health insurance options called Multi-State Plans. There are no major differences between multi-state plans and other plans, and it does NOT mean these plans provide out of state benefits, just that benefits meet minimum requirements from state to state. Always check the doctor’s networks for each individual plans, and remember that emergency care is covered within the continental US.

Plan Name Blue Cross Blue Shield Premier 101 Blue Cross Blue Shield Solution 102 Blue Cross Blue Shield Basic 103
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. $1,000 $3,750 $6,250
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max 20% 20% 30%
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) $5,800 $6,500 $7,150
Primary Care Office Visit First 3 visits $15, then 20% First 2 visits $0, then 20% First visit $0, then 30%
Specialist Office Visit 20% 20% 30%
Mental Illness Treatment and Substance Abuse Rehab Office Visit $0 $0 $0
Emergency Room $600 per occurrence copay, then 20% $750 per occurrence copay, then 20% $1,000 per occurrence copay, then 30%
Urgent Care $15 $15 $15e
Inpatient Hospital Service 20% 20% 30%
Outpatient Surgery 40% $300 per occurrence copay, then 40% $400 per occurrence copay, then 50%
Outpatient X-Rays and Diagnostic Imaging 40% 40% 50%
Outpatient Imaging (CT/PET Scans/MRIs) 40% 40% $500 per occurrence copay, then 50%
Network Blue Advantage HMO
HSA Eligible No No No
Outpatient Prescription Drugs – Preferred Pharmacy $0/$10/$50/$100/30% $0/$10/$50/$100/30% 20%/20%/30%/40%/50%
Outpatient Prescription Drugs – Non-Preferred Pharmacy $5/$15/$60/$110/30% $5/$15/$60/$110/30% 25%/25%/40%/50%/50%

Prescription Drug Utilization Benefit Management ProgramsSpecialty 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.

HSA Plan Comparison

Health Savings Accounts can reduce your out of pocket costs as well as your tax burden. BCBSTX offers the only HSAs in Texas. Learn more at our HSA Guide.

Plan Name Blue Advantage Bronze HMO 006 Blue Advantage Plus Bronze 104 Blue Advantage Silver HMO 103
Plan Brochure Plan Details Plan Details Plan Details
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. $6,500 $5,000 $3,750
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max None (Member pays 0% after deductible) 40% 0%
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) $6,500 $6,550 $3,750
Primary Care Office Visit 0% after deductible 40% $30
Specialist Office Visit 0% after deductible 40% 100% after deductible
Mental Illness Treatment and Substance Abuse Rehab Office Visit 0% after deductible 40% 40%
Emergency Room 0% after deductible 40% 40%
Urgent Care 0% after deductible $20 100% after deductible
Inpatient Hospital Service 0% after deductible 40% 100% after deductible
Outpatient Surgery 0% after deductible 50% 100% after deductible
Outpatient X-Rays and Diagnostic Imaging 0% after deductible 50% $100
Outpatient Imaging (CT/PET Scans/MRIs) 0% after deductible 50% 100% after deductible
Network Blue Advantage HMO
HSA Eligible Yes Yes Yes
Outpatient Prescription Drugs – Preferred Pharmacy 0% after deductible 30%/30%/40%/50%/50% 100% after deductible
Outpatient Prescription Drugs – Non-Preferred Pharmacy 0% after deductible 35%/35%/50%/50%/50% 100% after deductible
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.

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