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.
Recommended Plan
Blue Advantage Gold HMO 207
The Best Gold Plan
This plan is great for flat copays for PCP (Primary Care Physicians), specialists, urgent care, and mental health! This also has a $0 deductible and low coinsurance rates.
| Plan Name | Blue Advantage Gold HMO 206 | Blue Advantage Gold HMO 207 | Blue Advantage Gold HMO 603 | Blue Advantage Gold HMO 706 |
| Summary of Benefits | Benefit Summary | Benefit Summary | Benefit Summary | Benefit Summary |
| Deductible a specified amount of money that the insured must pay before an insurance company will pay a claim. | $750 | $0 | $1,500 | $1,500 |
| Out-of-Pocket Maximum An 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) | $9,450 | $9,450 | $5,000 | $8,700 |
| Primary Care Office Visit | $30 copay | $35 copay | $45/visit; deductible does not apply | $30/visit; deductible does not apply |
| Specialist Office Visit | 40% | $70 copay | 40% | $60/visit; deductible does not apply |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | 40% coinsurance for office visits; 20% coinsurance for other outpatient services |
$35/office visit; No Charge for other outpatient services |
40% coinsurance | $30/office visit; deductible does not apply; 25% coinsurance for other outpatient services |
| Emergency Room | $950 per visit plus 40% | $750/visit | $950/visit plus 40% coinsurance | 25% coinsurance |
| Urgent Care | $45/visit, deductible does not apply | $60/visit | $60/visit; deductible does not apply | $45/visit; deductible does not apply |
| If you have a hospital stay | Facility Fee: $850/visit plus 40% coinsurance | Facility Fee: $1,500 per day copay | $850/visit plus 40% coinsurance | 25% coinsurance |
| Outpatient Surgery | Freestanding Facility: $600/visit plus 20% coinsurance Hospital: $600/visit plus 40% coinsurance |
Freestanding Facility: $250/visit Hospital: $500/visit |
Freestanding Facility: $600/visit plus 20% coinsurance Hospital: $600/visit plus 40% coinsurance |
25% coinsurance |
| Outpatient X-Rays and Diagnostic Imaging | Freestanding Facility: 20% coinsurance Hospital: 40% coinsurance |
Freestanding Facility: $10/test Hospital: $20/test |
Freestanding Facility: 20% coinsurance Hospital: 40% coinsurance |
25% coinsurance |
| Outpatient Imaging (CT/PET Scans/MRIs) | Freestanding Facility: 20% coinsurance Hospital: 40% coinsurance |
Freestanding Facility: $125/test Hospital: $250/test |
Freestanding Facility: 20% coinsurance Hospital: 40% coinsurance |
25% coinsurance |
| Network | Blue Advantage HMO | |||
| HSA Eligible | No | No | No | No |
| If you need drugs to treat your illness or condition | ||||
| Generic Preferred | Retail – Preferred Participating – No Charge Participating – $10/prescription Mail – No Charge; deductible does not apply |
Retail – Preferred Participating – No Charge Participating – $10/prescription Mail – No Charge |
Retail – Preferred Participating – No Charge Participating – $10/prescription Mail – No Charge; deductible does not apply |
Retail – Preferred Participating – $15/prescription Participating – $15/prescription Mail – $45/prescription; deductible does not apply |
| Generic Non Preferred | Retail – Preferred Participating – $10/prescription Participating – $20/prescription Mail – $30/prescription; deductible does not apply |
Retail – Preferred Participating – $10/prescription Participating – $20/prescription Mail – $30/prescription |
Retail – Preferred Participating – $10/prescription Participating – $20/prescription Mail – $30/prescription; deductible does not apply |
Retail – Preferred Participating – $15/prescription Participating – $15/prescription Mail – $45/prescription; deductible does not apply |
| Brand Drugs Preferred | Retail – Preferred Participating – $50/prescription Participating – $60/prescription Mail – $150/prescription; deductible does not apply |
Retail – Preferred Participating – $50/prescription Participating – $70/prescription Mail – $150/prescription |
Retail – Preferred Participating – $50/prescription Participating – $60/prescription Mail – $150/prescription; deductible does not apply |
Retail – Preferred Participating – $30/prescription Participating – $30/prescription Mail – $90/prescription; deductible does not apply |
| Brand Drugs Non Preferred | Retail – Preferred Participating – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
Retail – Preferred Participating – $100/prescription Participating – $120/prescription Mail – $300/prescription |
Retail – Preferred Participating – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
Retail – Preferred Participating – $60/prescription Participating – $60/prescription Mail – $180/prescription; deductible does not apply |
| Specialty Drugs Preferred | 45% coinsurance | 40% Coinsurance | 45% coinsurance | $250/prescription; deductible does not apply |
| Specialty Drugs Non Preferred | 50% coinsurance | 50% Coinsurance | 50% coinsurance | $250/prescription; deductible does not apply |
| 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. | ||
*Percentages represent amount of coinsurance
**Not available on the health exchange marketplace (not subsidy eligible)
| Plan Name | Blue Advantage Plus Gold 203 | Blue Advantage Plus Gold HMO 706 | Blue Advantage Plus Gold HMO 803 |
| Summary of Benefits | Benefit Summary | Benefit Summary | Benefit Summary |
| Deductible a specified amount of money that the insured must pay before an insurance company will pay a claim. | $850 | $1,500 | $1,850 |
| Out-of-Pocket Maximum An 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) | $9,450 | $8,700 | $9,450 |
| Primary Care Office Visit | $20/visit; deductible does not apply | $30/visit; deductible does not apply | No Charge; deductible does not apply |
| Specialist Office Visit | $45/visit; deductible does not apply | $60/visit; deductible does not apply | $20/visit; deductible does not apply |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | $20/office visit; deductible does not apply; 20% coinsurance for other outpatient services |
$30/office visit; deductible does not apply; 25% coinsurance for other outpatient services |
No Charge; deductible does not apply 20% coinsurance for other outpatient services |
| Emergency Room | $950/visit plus 30% coinsurance | 25% coinsurance | $950 per occurrence deductible, then 30% |
| Urgent Care | $45/visit; deductible does not apply | $45/visit; deductible does not apply | First two urgent care visits $0; then $45 copay for all visits after |
| Inpatient Hospital Service | $850/visit plus 30% | 25% coinsurance | $850/visit plus 30% coinsurance |
| Outpatient Surgery | Freestanding Facility: 20% coinsurance Hospital: 30% coinsurance |
25% coinsurance | Freestanding Facility: 20% coinsurance Hospital: 30% coinsurance |
| Outpatient X-Rays and Diagnostic Imaging | Freestanding Facility: 20% coinsurance Hospital: 30% coinsurance |
25% coinsurance | Freestanding Facility: 20% coinsurance Hospital: 30% coinsurance |
| Outpatient Imaging (CT/PET Scans/MRIs) | Freestanding Facility: 20% coinsurance Hospital: 30% coinsurance |
25% coinsurance | Freestanding Facility: 20% coinsurance Hospital: 30% coinsurance |
| Network | Blue Advantage HMO | Blue Advantage HMO | Blue Advantage HMO |
| HSA Eligible | No | No | No |
| Outpatient Prescription Drugs Tiers | |||
| Generic drugs (Preferred) |
Retail – Preferred Participating – No Charge Participating – $10/prescription Mail – No Charge; deductible does not apply |
Generic Drugs all: Retail – Preferred Participating – $15/prescription Participating – $15/prescription Mail – $45/prescription; deductible does not apply |
Retail – Preferred Participating – No Charge Participating – $10/prescription Mail – No Charge; deductible does not apply |
| Generic drugs (Non-preferred) |
Retail – Preferred Participating – $10/prescription Participating – $20/prescription Mail – $30/prescription; deductible does not apply |
Retail – Preferred Participating – $30/prescription Participating – $30/prescription Mail – $90/prescription; deductible does not apply |
Retail – Preferred Participating – $10/prescription Participating – $20/prescription Mail – $30/prescription; deductible does not apply |
| Brand drugs (Preferred) |
Retail – Preferred Participating – $50/prescription Participating – $60/prescription Mail – $150/prescription; deductible does not apply |
Retail – Preferred Participating – $30/prescription Participating – $30/prescription Mail – $90/prescription; deductible does not apply |
Retail – Preferred Participating – $50/prescription Participating – $60/prescription Mail – $150/prescription; deductible does not apply |
| Brand drugs (Non-preferred) | Retail – Preferred Participating – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
Retail – Preferred Participating – $60/prescription Participating – $60/prescription Mail – $180/prescription; deductible does not apply |
Retail – Preferred Participating – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
| Specialty drugs (Preferred) |
45% coinsurance | Specialty Drugs: $250/prescription; deductible does not apply | 45% coinsurance |
| Specialty drugs (Non-Preferred) |
50% coinsurance | Specialty Drugs: $250/prescription; deductible does not apply | 50% coinsurance |
| 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. | ||
| Plan Name | MyBlue Health 403 | MyBlue Health 808 |
| Summary of Benefits | Benefit Summary | Benefit Summary |
| Deductible a specified amount of money that the insured must pay before an insurance company will pay a claim. | $1.000 | $1,500 |
| Out-of-Pocket Maximum An 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) | $9,450 | $8,700 |
| Primary Care Office Visit | Select PCP: No Charge; deductible does not apply All other providers: $20/visit; deductible does not apply |
$30/visit; deductible does not apply |
| Specialist Office Visit | 30% coinsurance | $60/visit; deductible does not apply |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | 30% coinsurance for office visits; 20% coinsurance for other outpatient services |
$30/office visit; deductible does not apply; 25% coinsurance for other outpatient services |
| Emergency Room | $950/visit plus 30% coinsurance | 25% coinsurance |
| Urgent Care | $30/visit; deductible does not apply | $45/visit; deductible does not apply |
| Inpatient Hospital Service | $850/visit plus 30% coinsurance | 25% coinsurance |
| Outpatient Surgery | Freestanding Facility: 20% coinsurance Hospital: 30% coinsurance |
25% coinsurance |
| Outpatient X-Rays and Diagnostic Imaging | Freestanding Facility (including bloodwork performed by a Select PCP): 20% coinsurance Hospital (including bloodwork): 30% coinsurance In Office: (Certain X-Rays, Ultrasounds, and ECGs ordered by Select PCP): No Charge; deductible does not apply |
25% coinsurance |
| Outpatient Imaging (CT/PET Scans/MRIs) | Freestanding Facility: 20% coinsurance Hospital: 30% coinsurance |
25% coinsurance |
| Network | MyBlue Health | MyBlue Health |
| HSA Eligible | No | No |
| Outpatient Prescription Drugs Tiers | ||
| Generic drugs (Preferred) |
Retail – Preferred Participating – $5/prescription Participating – $10/prescription Mail – $15/prescription; deductible does not apply |
Retail – Preferred Participating – $15/prescription Participating – $15/prescription Mail – $45/prescription; deductible does not apply |
| Generic drugs (Non-preferred) |
Retail – Preferred Participating – $15/prescription Participating – $25/prescription Mail – $45/prescription; deductible does not apply |
Retail – Preferred Participating – $15/prescription Participating – $15/prescription Mail – $45/prescription; deductible does not apply |
| Brand drugs (Preferred) |
Retail – Preferred Participating – 30% coinsurance Participating – 35% coinsurance Mail – 30% coinsurance |
Retail – Preferred Participating – $30/prescription Participating – $30/prescription Mail – $90/prescription; deductible does not apply |
| Brand drugs (Non-preferred) | Retail – Preferred Participating – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
Retail – Preferred Participating – $60/prescription Participating – $60/prescription Mail – $180/prescription; deductible does not apply |
| Specialty drugs (Preferred) |
45% coinsurance | Specialty Drugs: $250/prescription; deductible does not apply |
| Specialty drugs (Non-Preferred) |
50% coinsurance | Specialty Drugs: $250/prescription; deductible does not apply |
| 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. | ||
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.
BlueCross BlueShield Texas
Individual Plan Guides
Questions?
(312) 726-6565
Monday - Friday
8am - 6pm CST
TESTING #1