BlueCross BlueShield of Texas

Silver Health Plans 2023

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.

Plan Name	Blue Advantage Silver HMO 205	Blue Advantage Silver HMO 306	Blue Advantage Silver HMO 601	Blue Advantage Silver HMO 705
Summary of Benefits	Benefit Summary	Benefit Summary	Benefit Summary	Benefit Summary
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.	$2,050	$2,000	3,000	$5,800
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max	50%	50%	30%	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)	$9,100	$9,100	$9,100	$8,900
Primary Care Office Visit	$15 copay	$25 copay	$50 copay	$40 copay
Specialist Office Visit	50%	50%	$90 copay	$80 copay
Mental Illness Treatment and Substance Abuse Rehab Office Visit	50%	50%	$50 copay	$40 copay
Emergency Room	$950 per occurrence deductible, then 50%	$950 per occurrence deductible, then 50%	$650 per occurrence deductible, then 30%	40%
Urgent Care	$15 copay	$50 copay	$60 copay	$60 copay
Inpatient Hospital Service	$850 per occurrence deductible, then 50%	$850 per occurrence deductible, then 50%	$350 per occurrence deductible, then 30%	40%
Outpatient Surgery	$600 per occurrence copay, then 50%	$600 per occurrence deductible, then 50%	$300 per occurrence deductible, then 30%	40%
Outpatient X-Rays and Diagnostic Imaging	50%	50%	30%	40%
Outpatient Imaging (CT/PET Scans/MRIs)	50%	50%	$250 per occurrence deductible, then 30%	40%
Network	Blue Advantage HMO
HSA Eligible	No	Yes	No	No
Outpatient Prescription Drugs – Preferred Pharmacy	$5/$15/30%/35%/45%/50%	$5/$15/$75/35%/45%/50%	$0/$10/$50/$100/$150/$250	$20/$40/$80/$350
Outpatient Prescription Drugs – Non-Preferred Pharmacy	$15/$25/35%/40%/45%/50%	$15/$25/$85/40%/45%/50%	$0/$20/$70/$120/$150/$250	$20/$40/$80/$350

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	Blue Advantage Plus Silver 202	Blue Advantage Plus Silver 306	Blue Advantage Plus Silver 605	Blue Advantage Plus Silver 705	MyBlue Health Silver 405
Summary of BenefitsWhat % you pay after your deductible has been met and before your out of pocket max	Benefit Summary	Benefit Summary	Benefit Summary	Benefit Summary	Benefit Summary
Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.	$1,500	$2,000	$0	$5,800	$2,700
CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max	50%	50%	50%	40%	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)	$9,100	$9,100	$9,100	$8,900	$9,100
Primary Care Office Visit	$25 copay	$25 copay	$105 copay	$40 copay	$0/$30
Specialist Office Visit	50%	50%	$130 copay	$80 copay	40%
Mental Illness Treatment and Substance Abuse Rehab Office Visit	50%	50%	$105 copay	$40 copay	30%
Emergency Room	$950 per occurrence deductible, then 50%	$950 per occurrence deductible, then 50%	$950 per occurrence deductible, then 50%	40%	$950 per occurrence copay, then 40%
Urgent Care	$15 copay	$50 copay	$60 copay	$60 copay	First two urgent care visits $0; then $50 copay for all visits after
Inpatient Hospital Service	$850 per occurrence deductible, then 50%	$850 per occurrence deductible, then 50%	$850 per occurrence deductible, then 50%	40%	$850 per occurrence deductible, then 40%
Outpatient Surgery	$600 per occurrence deductible, then 50%	$600 per occurrence deductible, then 50%	50%	40%	$600 per occurrence deductible, then 40%
Outpatient X-Rays and Diagnostic Imaging	50%	50%	50%	40%	40%
Outpatient Imaging (CT/PET Scans/MRIs)	50%	50%	50%	40%	40%
Network	Blue Advantage HMO				MyBlue Health
HSA Eligible	No	No	No	No	No
Outpatient Prescription Drugs – Preferred Pharmacy	$5/$15/30%/35%/45%/50%	$5/$15/$75/35%/45%/50%	$35/$40/50%/50%/50%/50%	$20/$40/$80/$350	$5/$15/30%/35%/45%/50%
Outpatient Prescription Drugs – Non-Preferred Pharmacy	$10/$25/35%/40%/45%/50%	$15/$25/$85/40%/45%/50%	$45/$50/50%/50%/50%/50%	$20/$40/$80/$350	$10/$25/35%/40%/45%/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.