BlueCross BlueShield of Texas 2025 Plan Guide

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Blue Advantage HMO Plans:

4 Bronze, 5 Silver, and 4 Gold

• Network: Blue Advantage HMO (BAV)
• Statewide existing network in all 254 counties
• Approximately 378 hospitals and 105,743 providers
• Helps keep costs lower and more predictable
• Personalized with a primary care provider (PCP) who coordinates all health care

Blue Advantage Plus:

4 Bronze, 4 Silver, and 3 Gold

• Network: Blue Advantage HMO
• Statewide existing network in all 254 counties
• Approximately 378 hospitals and 105,743 providers
• Greater flexibility
• Leverages the HMO network
• Some out-of-network benefits available

*Estimates as of 6/1/2021

**Estimates as of 6/20/23. Hospital counts are acute care unique parent PFINs (Practice Locations) –does not count satellite locations billed under another entity. During open enrollment, members who enroll in MyBlue Health plan will be able to choose their Select PCP for 2024 through Provider finder.

MyBlue Health:

2 Bronze, 2 Silver, 2 Gold

• Network: MyBlue Health^SM (BFT)
• Approximately 85 hospitals and 40,541 providers**
• THREE new counties including: Comal, McLennan, and Rockwall
• Members must choose a Select Primary Care Physician (PCP) from the county they live in, but they will be able to see them at any of the Select PCP’s locations. Select PCP groups are:
  • Comal County: BHS and CentroMed
  • McLennan County: Providence Health Alliance
  • Rockwall County: VillageMD and THR
• Retail members who choose a MyBlue Heath Select PCP will have a $0 copay for any scheduled PCP visit
• Members also receive $0 copay for the following services at MyBlue Health network clinics
  • Certain X-rays, ultrasounds, ECGs
  • Testing for allergies
  • Minor in-office procedures such as biopsy, wart removal etc.
  • Select immunizations and their administration
  • Chronic disease management programs
  • Health education programs and wellness services
  • Mental and behavioral health visits
  • Telehealth

Using PCP’s vs Select PCP’s

• Members must choose an in-network PCP. These include:
  • Participating Physician (family practitioner, internist, obstetrician/gynecologist, pediatrician)
  • Physician Assistant (PA)
  • Advanced Practice Registered Nurse (APRN)
  • Advanced Practice Nurse (APN)
• When using in-network Non-Select PCPs, members will access care at
  standard benefit level
• Members may choose a Select PCP within designated
  Practice Groups, which results in a $0 office visit copayment for
  scheduled PCP office visits

*Estimates as of 6/1/2021

**Estimates as of 6/20/23. Hospital counts are acute care unique parent PFINs (Practice Locations) –does not count satellite locations billed under another entity. During open enrollment, members who enroll in MyBlue Health plan will be able to choose their Select PCP for 2024 through Provider finder.

BlueCare Dental 

Dental care is vital to your overall health. That is why Blue Cross and Blue Shield of Texas (BCBSTX), a Division of Health Care Service Corporation, offers BlueCare Dental and BlueCare Dental 4 Kids SM. Our dental plans provide you with coverage for preventive services like checkups, cleanings and basic X-rays, as well as procedures like fillings, bridges and crowns.

BCBSTX offers a variety of plans to fit your family’s needs and budget with four plans for adults and three for children.

• All plans offer coverage for basic preventive services, including 100% coverage in-network for BlueCare Dental 1A plans.
• Plans also offer coverage for other dental procedures, including oral surgery, extractions, restorative work, and more*.
• We offer a range of monthly rates to fit your budget. Our new BlueCare Dental 1C plan features the lowest rates.
• Use the chart on the next page to compare plans and monthly rates to find the one that works best for you.

Downloadable Summary of Benefits

BlueCare 1A

BlueCare 1B

BlueCare 2A

BlueCare 1C

BlueCare Vision Basic:

• Coverage Plus Central platform
  • Platform used to enroll new members into these plans
• BlueCare Vision Effective Dates
  • Policy length is 12 months from the effective date
    Updated policy: enrollment can now be completed anytime during the
    month to be effective the 1st day of the next month
• BlueCare Vision Cancellation
  • Members who wish to cancel can do so online on the Coverage Plus Central platform or call the Trionfo customer service number

Pediatric Vision Benefit

Blue365 is just one more advantage of being a Blue Cross and Blue Shield of Texas (BCBSTX), a division of Health Care Service Corporation, member. With this program, you may save money on health and wellness products and services from top retailers that are not covered by insurance. There are no claims to file and no referrals or pre-authorizations. Once you sign up for Blue365 at blue365deals.com/BCBSTX, weekly “Featured Deals” will be emailed to you. These deals offer special savings for a short period of time.

Below are some of the ongoing deals offered to Blue365 members:

Davis VisionSM | TruVision®
You may save on eyeglasses as well as contact lenses, exams and accessories. Davis Vision is made up of national and regional retail stores as well as local eye doctors. You may get possible savings on laser vision correction through the TLC/TruVision group.

TruHearing® | Beltone™
You may get possible savings on hearing tests, evaluations and hearing aids. Discounts may also be available for your immediate family members.

Procter & Gamble (P&G) Dental Products
You may get savings on dental packages with Oral B® power toothbrushes and Crest® products. Packages may include items such as an electric toothbrush, mouth rinse, teeth whiteners and floss.

Dental Solutions
You may get dental savings with Dental Solutions. You may receive a dental discount card that provides access to discounts of up to 50 percent at more than 61,000 dentists and more than 185,000 locations.*

CORD:USE® | CorCell®
You can protect your family’s cord blood at a state-ofthe- art laboratory using high-quality cord blood banking practices and technologies. Cord blood contains stem cells (like those in bone marrow) that have the ability to develop into additional cells and can be used to treat possible life-threatening diseases in the future. You may save on cord blood processing and storage fees. Jenny Craig® | Seattle Sutton’s® | Nutrisystem®. You may reach your weight loss goals with savings from leading programs. You may save on healthy meals, membership fees (where applicable), nutritional products and services.

Retrofit
Receive 15 percent off Retrofit’s online, private weight loss coaching sessions. Retrofit includes the use of a wireless Fitbit® device and smart scale, one-on-one
videoconferencing with a personal team of experts and unlimited online support. You will enjoy flexibility in scheduling and the ability to meet with coaches anywhere there is an Internet connection. Reebok | SKECHERS® Reebok, a trusted brand for more than 100 years, makes top athletic equipment for all people, from professional athletes to kids playing soccer. SKECHERS, an award winning leader in the footwear industry, offers exclusive pricing on select Performance, Sport, Work and Corporate Casual styles. You will enjoy 20 percent off plus free shipping for your online orders.

Life Time Fitness®
Life Time Fitness offers total health fitness to fit your level, interests, schedule and budget. For new members, Life
Time Fitness offers a $0 online signup fee.**

SeniorLink Care™
With SeniorLink Care, you may find support to help your aging family members or friends lead fulfilling and comfortable lives. From planning care to helping
caregivers, SeniorLink Care assists older adults and their loved ones in finding the programs and services they may need most. You can save on a three- or 12-month membership.

Handstand Kids
Handstand Kids brings the family together in the kitchen, spending more time cooking and eating healthy, delicious meals. The Handstand Kids Cookbook series features the languages and cuisines of Italy, Mexico, China and many other countries. Every book also introduces the language and culture of each country. You may save up to 25 percent on cooking accessories and Cookbook Kits.

BCBSTX switched from a 4 tier formulary to a 6 tier formulary in 2019.

• Most plans have six prescription drug payment level tiers: preferred generic, non-preferred generic, preferred brand, non-preferred brand, preferred specialty, non-preferred specialty
• Standardized plans have four prescription drug payment level tiers: generic, preferred brand, non-preferred brand, and specialty
• All plans include a drug list and Preferred Pharmacy Network**

BCBSTX also offers ways for you to save time and money on your prescriptions.

• Cost savings: You may pay less when you choose generic medicines from our drug list. You also may save when you get up to a 30-day supply of a covered prescription drug from an in-network pharmacy. Talk to your doctor about what is right for you
• Time savings: Maintenance medications are those drugs you take on a regular basis. You can have up to a 90-day supply of these medications delivered directly to you through the mail order program or at a retail preferred pharmacy participating in the Preferred Pharmacy Network.5
• Online resources: You can search the drug list, find a pharmacy, see your claims, order home delivery, and get an estimate of your costs for a medication 24/7 by logging in to Blue Access for MembersSM (BAMSM) at bcbstx.com.

*Estimates as of 7/31/2022

**A “preferred” or “participating” pharmacy has a contract with BCBSTX’s pharmacy benefit manager (Prime Therapeutics) to provide pharmacy services at a negotiated rate. A pharmacy benefit
manager administers prescription drug benefits for a health plan. The terms “preferred” and “participating” should not be construed as a recommendation, referral or any other statement as
to the ability or quality of such pharmacy.

New 4 Tier Benefit Design

• New requirement for CMS Standardized Plan Offerings
• Available to On-Exchange plans
• Drug lists are exactly the same for 4 Tiers and 6 Tier prescription plans
• Some brands may be placed in generic Tiers and some generics may be placed in brand Tiers
• 87.3% of prescriptions filled (2022 YTD) fall into Tiers 1 and 2 of a 6 Tier benefit structure
• 43% of all medications on the formulary are in the first two Tiers of a 6 Tier benefit structure

Pharmacy Networks 

• Contains a tiered network structure that categorizes in-network pharmacies into two buckets: Preferred and Non-Preferred
• Members may pay a lower copay/coinsurance at an in-network Preferred pharmacy vs. using an in-network Non-Preferred pharmacy
• Members can get up to a 90-day supply of medication from a Preferred pharmacy or a 30-day supply of medication from a Non-Preferred pharmacy
• 90-day supplies are 3 times the 30-day retail copay via Preferred pharmacies and mail order through Express Scripts® Pharmacy
• Select Independent Pharmacies may be included in a Preferred Pharmacy Network

Specialty Pharmacy Program

Specialty medications are used to treat conditions such as Multiple Sclerosis, Rheumatoid Arthritis, Cancer, and Cystic Fibrosis. Drugs may have special handling/storage requirements.

• Medications are limited to a 30-day supply due to high cost and to prevent waste Self-administered products are standardly covered under the pharmacy benefit while physician-administered products are covered under the medical benefit
• We deliver savings on specialty drugs for our clients and member through Prime’s Specialty Network offering
• Accredo, our specialty pharmacy partner, has pharmacies across the country that allows drugs to be dispensed from the pharmacy location closest to the patient