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.
Recommended Plan
Blue Advantage Plus Silver 705
The Best Silver Plan
This plan is great for flat copays for PCPs (Primary Care Physicians), specialists, urgent care, and mental health!
| Plan Name | Blue Advantage Silver HMO 205 | Blue Advantage Silver HMO 306 | Blue Advantage Silver HMO 601 |
| 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. | $1,950 | $2,000 | 3,000 |
| Coinsurance – What % you pay after your deductible has been met and before your out of pocket max | 50% | 50% | 30% |
| 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 | $9,450 |
| Primary Care Office Visit | $15/visit; deductible does not apply | $25/visit; deductible does not apply | $40/visit; deductible does not apply |
| Specialist Office Visit | 50% coinsurance | 50% | $85/visit; deductible does not apply |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | 50% coinsurance for office visits; 40% coinsurance for other outpatient services |
50% coinsurance for office visits; 40% coinsurance for other outpatient services |
$40/office visit; deductible does not apply; 30% coinsurance for other outpatient services |
| Emergency Room | $950/visit plus 50% coinsurance | $950/visit plus 50% coinsurance | $650/visit plus 30% coinsurance |
| Urgent Care | $25/visit; deductible does not apply | $40/visit; deductible does not apply | $60/visit; deductible does not apply |
| Inpatient Hospital Service | Facility Fee: $850/visit plus 50% coinsurance | Facility Fee: $850/visit plus 50% coinsurance | Facility Fee: $350/visit plus 30% coinsurance |
| Outpatient Surgery | Freestanding Facility: $600/visit plus 40% coinsurance Hospital: $600/visit plus 50% coinsurance |
Freestanding Facility: $600/visit plus 40% coinsurance Hospital: $600/visit plus 50% coinsurance |
$300/visit plus 30% coinsurance |
| Outpatient X-Rays and Diagnostic Imaging | Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance |
Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance |
30% coinsurance |
| Outpatient Imaging (CT/PET Scans/MRIs) | Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance |
Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance |
$250/test plus 30% |
| Network | Blue Advantage HMO | ||
| HSA Eligible | No | No | No |
| Outpatient Prescription Drugs | |||
| Generic drugs (Preferred) |
Retail – Preferred Participating – $5/prescription Participating – $15/prescription Mail – $15/prescription; deductible does not apply |
Retail – Preferred Participating – $5/prescription Participating – $15/prescription Mail – $15/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 – $15/prescription Participating – $25/prescription Mail – $45/prescription; deductible does not apply |
Retail – Preferred Participating – $5/prescription Participating – $15/prescription Mail – $15/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 – 30% coinsurance Participating – 35% coinsurance Mail – 30% coinsurance |
Retail – Preferred Participating – $75/prescription Participating – $85/prescription Mail – $225/prescription; deductible does not apply |
Retail – Preferred Participating – $50/prescription Participating – $70/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 – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
Retail – Preferred Participating – $100/prescription Participating – $120/prescription Mail – $300/prescription; deductible does not apply |
| Specialty drugs (Preferred) |
45% coinsurance | 45% coinsurance | $150/prescription; deductible does not apply |
| Specialty drugs (Non-Preferred) |
50% coinsurance | 50% coinsurance | $250/prescription; deductible does not apply |
| Plan Name | Blue Advantage Silver HMO 705 | Blue Advantage Silver HMO 801 |
| 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. | $5,900 | $3,000 |
| Coinsurance- What % you pay after your deductible has been met and before your out of pocket max | 40% | 40% |
| 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) | $9,100 | $9,450 |
| Primary Care Office Visit | $40/visit; deductible does not apply | $50/visit; deductible does not apply |
| Specialist Office Visit | $80/visit; deductible does not apply | $95/visit; deductible does not apply |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | $40/office visit; deductible does not apply; 40% coinsurance for other outpatient services |
$50/office visit; deductible does not apply; 40% coinsurance for other outpatient services |
| Emergency Room | 40% coinsurance | 40% coinsurance |
| Urgent Care | $60/visit; deductible does not apply | $60/visit; deductible does not apply |
| Inpatient Hospital Service | Facility Fee: 40% coinsurance | 40% coinsurance |
| Outpatient Surgery | 40% coinsurance | Freestanding Facility: 30% coinsurance Hospital: 40% coinsurance |
| Outpatient X-Rays and Diagnostic Imaging | 40% coinsurance | Freestanding Facility: 30% coinsurance Hospital: 40% coinsurance |
| Outpatient Imaging (CT/PET Scans/MRIs) | 40% coinsurance | Freestanding Facility: 30% coinsurance Hospital: 40% coinsurance |
| Network | Blue Advantage HMO | |
| HSA Eligible | No | No |
| Outpatient Prescription Drugs | ||
| Generic drugs (Preferred) |
Retail – Preferred Participating – $20/prescription Participating – $20/prescription Mail – $60/prescription; deductible does not apply |
No Charge after deductible |
| Generic drugs (Non-Preferred) |
Retail – Preferred Participating – $20/prescription Participating – $20/prescription Mail – $60/prescription; deductible does not apply |
10% coinsurance |
| Brand drugs (Preferred) |
Retail – Preferred Participating – $40/prescription Participating – $40/prescription Mail – $120/prescription; deductible does not apply |
20% coinsurance |
| Brand drugs (Non-Preferred) |
Retail – Preferred Participating – $80/prescription Participating – $80/prescription Mail – $240/prescription |
30% coinsurance |
| Specialty drugs (Preferred) |
$350/prescription | 40% coinsurance |
| Specialty drugs (Non-Preferred) |
$350/prescription | 50% coinsurance |
| Plan Name |
Blue Advantage Plus Silver 202 |
Blue Advantage Plus Silver 306 | Blue Advantage Plus Silver 605 | Blue Advantage Plus Silver 705 |
| Summary of Benefits- What % you pay after your deductible has been met and before your out of pocket max | Benefit Summary | Benefit Summary | Benefit Summary | Benefit Summary |
| Deductible – specified amount of money that the insured must pay before an insurance company will pay a claim. | $1,500 | $2,000 | $0 | $5,900 |
| Coinsurance- What % you pay after your deductible has been met and before your out of pocket max | 50% | 50% | 50% | 40% |
| 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 | $9,450 | $9,100 |
| Primary Care Office Visit | $25/visit; deductible does not apply | $25/visit; deductible does not apply | $115/visit | $40/visit; deductible does not apply |
| Specialist Office Visit | 50% coinsurance | 50% coinsurance | $135/visit | $80/visit; deductible does not apply |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | 50% coinsurance for office visits; 30% coinsurance for other outpatient services |
50% coinsurance for office visits; 40% coinsurance for other outpatient services |
$115/office visit; 40% coinsurance for other outpatient services |
$40/office visit; deductible does not apply; 40% coinsurance for other outpatient services |
| Emergency Room | $950/visit plus 50% coinsurance | $950/visit plus 50% coinsurance | $950/visit plus 50% coinsurance | 40% coinsurance |
| Urgent Care | $40/visit; deductible does not apply | $40/visit; deductible does not apply | $170/visit | $60/visit; deductible does not apply |
| Inpatient Hospital Service | Facility Fee: $850/visit plus 50% coinsurance | Facility Fee: $850/visit plus 50% coinsurance | Facility Fee: $850/visit plus 50% coinsurance | Facility Fee: 40% coinsurance |
| Outpatient Surgery | Freestanding Facility: $600/visit plus 30% coinsurance Hospital: $600/visit plus 50% coinsurance |
Freestanding Facility: $600/visit plus 40% coinsurance Hospital: $600/visit plus 50% coinsurance |
Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance |
40% coinsurance |
| Outpatient X-Rays and Diagnostic Imaging | Freestanding Facility: 30% coinsurance Hospital: 50% coinsurance |
Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance |
Freestanding Facility: $50/test plus 40% coinsurance; X-Rays: 40% coinsurance Hospital: $50/test plus 50% coinsurance; X-Rays: 50% coinsurance |
40% coinsurance |
| Outpatient Imaging (CT/PET Scans/MRIs) | Freestanding Facility: 30% coinsurance Hospital: 50% coinsurance |
Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance |
Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance |
40% coinsurance |
| Network | Blue Advantage HMO | |||
| HSA Eligible | No | No | No | No |
| Outpatient Prescription Drugs | ||||
| Generic Drugs (Preferred) | Retail – Preferred Participating – $5/prescription Participating – $10/prescription Mail – $15/prescription; deductible does not apply |
Retail – Preferred Participating – $5/prescription Participating – $15/prescription Mail – $15/prescription; deductible does not apply |
Retail – Preferred Participating – $40/prescription Participating $50/prescription Mail – $120/prescription |
Retail – Preferred Participating – $20/prescription Participating – $20/prescription Mail – $60/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 – $25/prescription Mail – $45/prescription; deductible does not apply |
Retail – Preferred Participating – $45/prescription Participating – $55/prescription Mail – $135/prescription |
Retail – Preferred Participating – $20/prescription Participating – $20/prescription Mail – $60/prescription; deductible does not apply |
| Brand Drugs (Preferred) | Retail – Preferred Participating – 30% coinsurance Participating – 35% coinsurance Mail – 30% coinsurance |
Retail – Preferred Participating – $75/prescription Participating – $85/prescription Mail – $225/prescription; deductible does not apply |
Retail – Preferred Participating – 50% coinsurance Participating – 50% coinsurance Mail – 50% coinsurance |
Retail – Preferred Participating – $40/prescription Participating – $40/prescription Mail – $120/prescription; deductible does not apply |
| Brand Drugs (Non-Preferred) | Retail – Preferred Participating – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
Retail – Preferred Participating – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
50% coinsurance | Retail – Preferred Participating – $80/prescription Participating – $80/prescription Mail – $240/prescription |
| Specialty Drugs (Preferred) | 45% coinsurance | 45% coinsurance | 50% coinsurance | $350/prescription |
| Specialty Drugs (Non-Preferred) | 50% coinsurance | 50% coinsurance | 50% coinsurance | $350/prescription |
| Plan Name | MyBlue Health Silver 405 | MyBlue Health Silver 807 |
| Summary of Benefits- What % you pay after your deductible has been met and before your out of pocket max | Benefit Summary | Benefit Summary |
| Deductible – specified amount of money that the insured must pay before an insurance company will pay a claim. | $2,250 | $5,900 |
| Coinsurance- What % you pay after your deductible has been met and before your out of pocket max | 40% | 40% |
| 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 | $9,100 |
| Primary Care Office Visit | Select PCP: No Charge; deductible does not apply/ All other providers: $30/visit; deductible does not apply |
$40/visit; deductible does not apply |
| Specialist Office Visit | 40% coinsurance | $80/visit; deductible does not apply |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | 40% coinsurance for office visits; 30% coinsurance for other outpatient services |
$40/office visit; deductible does not apply; 40% coinsurance for other outpatient services |
| Emergency Room | $950/visit plus 40% coinsurance | 40% coinsurance |
| Urgent Care | $45/visit; deductible does not apply | $60/visit; deductible does not apply |
| Inpatient Hospital Service | Facility Fee: $850/visit plus 40% coinsurance | Facility Fee: 40% coinsurance |
| Outpatient Surgery | Freestanding Facility: $600/visit plus 30% coinsurance Hospital: $600/visit plus 50% coinsurance |
40% coinsurance |
| Outpatient X-Rays and Diagnostic Imaging | Freestanding Facility: 30% coinsurance Hospital: 50% coinsurance |
40% coinsurance |
| Outpatient Imaging (CT/PET Scans/MRIs) | Freestanding Facility: 30% coinsurance Hospital: 50% coinsurance |
40% coinsurance |
| Network | MyBlue Health | |
| HSA Eligible | No | No |
| Outpatient Prescription Drugs | ||
| Generic Drugs (Preferred) | Retail – Preferred Participating – $5/prescription Participating – $10/prescription Mail – $15/prescription; deductible does not apply |
Retail – Preferred Participating – $20/prescription Participating – $20/prescription Mail – $60/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 – $20/prescription Participating – $20/prescription Mail – $60/prescription; deductible does not apply |
| Brand Drugs (Preferred) | Retail – Preferred Participating – 30% coinsurance Participating – 35% coinsurance Mail – 30% coinsurance |
Retail – Preferred Participating – $40/prescription Participating – $40/prescription Mail – $120/prescription; deductible does not apply |
| Brand Drugs (Non-Preferred) | Retail – Preferred Participating – 35% coinsurance Participating – 40% coinsurance Mail – 35% coinsurance |
Retail – Preferred Participating – $80/prescription Participating – $80/prescription Mail – $240/prescription |
| Specialty Drugs (Preferred) | 45% coinsurance | $350/prescription |
| Specialty Drugs (Non-Preferred) | 50% coinsurance | $350/prescription |
| 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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