BCBSTX 2023 Plan Guide
Blue Cross Blue Shield of Texas
BCBSTX 2021 Plans
Blue Cross and Blue Shield 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 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.
| Gold | Blue Advantage Plus Gold | Blue Advantage Plus Gold HMO |
|---|---|---|
| 203 | 306 | |
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $750 | $0 |
| CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 30% | 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)2 | $7,900 | $7,900 |
| Primary Care Office Visit | $15 | $20 |
| Specialist Office Visit | $15 | $50 |
| Mental Illness Treatment and Substance Abuse Rehabilitation Office Visit | $15 | $20 |
| Emergency Room | $950 per occurrence deductible, then 30% | $750 |
| Urgent Care | $50 (Deductible does not apply) | $50 |
| 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 | $0/$10 | $50/$70/$150 |
| Outpatient Prescription Drugs – Non-Preferred Pharmacy 6,7 | $10/$20/$30 | $10/$20/$30 |
| 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. | |
- 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.
- 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.
- All percentages shown are of the allowable amount for covered services.
- 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.
- 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.
- Prescription benefit coverage starts after annual medical deductible has been met, not counting copays.
- Six prescription drug payment level tiers: Preferred Generics / Non-Preferred Generics / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty.
- 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 | 202 | 306 | 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 | $1,000 | $2,000 | $1,900 | $3,250 |
| CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 30%-50% | 30%-50% | 35%-40% | 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 | $7,900 | $7,900 | $7,900 | $6,850 |
| Primary Care Office Visit | $10 | 25% | $25 First two visits, then 50% | First three visits $0, then 20% |
| Specialist Office Visit | 50% | 100% after deductible | 50% | 20% |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | 50% | 50% | $30 | $0 |
| Emergency Room | $950 per occurence copay, then 50% | $950 per occurence copay, then 50% | $850 + 50% coinsurance | $600 per occurence copay, then 20% |
| Urgent Care | $15 | $50 | $50 | $20 |
| Inpatient Hospital Services | $850 per occurence copay, then 50% | $850 per occurrence copay, then 50% | $850 per occurrence copay, then 50% | $400 per occurence copay, then 40% |
| Outpatient Surgery5 | $300 per occurence copay, then 30% | $600 per occurrence copay, then 40% | $600 per occurrence copay, then 40% | $300 per occurence copay, then 40% |
| Outpatient X-Rays and Diagnostic Imaging5 | 50% | 40% | 40% | $2,750 |
| Outpatient Imaging (CT/PET Scans/MRIs)5 | 30% | 40%-50% | 20% | 40% |
| Network | Blue Advantage HMO | Blue Advantage HMO | ||
| HSA Eligible6 | No | Yes | No | No |
| Outpatient Prescription Drugs – Preferred Pharmacy7 8 | $5/$10/$15 | $5/$10/$15 | $15/$15/$50/$100/40% | $0/$10/$50/$100/30% |
| Outpatient Prescription Drugs – Non-Preferred Pharmacy7 8 | $15/$25/$45 | $15/$25/$45 | $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. | $6,000 | $3,150 |
| 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 | $7,900 | $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 | 50% | $600 per occurrence deductible, then 30% |
| Outpatient X-Rays and Diagnostic Imaging4 | 40% | 30% |
| Outpatient Imaging (CT/PET Scans/MRIs)4 | 40% | 30% |
| Network | ||
| HSA Eligible5 | No | Yes |
| Outpatient Prescription Drugs – Preferred Pharmacy 6 7 | $15/$25/$45 | 30% |
| Outpatient Prescription Drugs – Non-Preferred Pharmacy 6 7 | $25/$35/$75 | 35% |
| 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. | |
- 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.
- 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.
- All percentages shown are of the allowable amount for covered services.
- 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.
- 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.
- Prescription benefit coverage starts after annual medical deductible has been met, not counting copays.
- Six prescription drug payment level tiers: Preferred Generics / Non-Preferred Generics / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty.
- 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 |
BCBSTX 2024 Plans
BCBSTX 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. | |
- 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.
- 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.
- All percentages shown are of the allowable amount for covered services.
- 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.
- 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.
- Prescription benefit coverage starts after annual medical deductible has been met, not counting copays.
- Six prescription drug payment level tiers: Preferred Generics / Non-Preferred Generics / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty.
- 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. | |
- 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.
- 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.
- All percentages shown are of the allowable amount for covered services.
- 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.
- 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.
- Prescription benefit coverage starts after annual medical deductible has been met, not counting copays.
- Six prescription drug payment level tiers: Preferred Generics / Non-Preferred Generics / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty.
- 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 | English ● Spanish |
| BCBSTX Silver Plan Comparison Chart | English ● Spanish |
| BCBSTX Bronze Plan Comparison Chart | English ● Spanish |
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: [email protected]
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 |
Find What Plans Your Doctor Accepts
Find Every Plan In Your Area Calculate Your Subsidy Live Chat Our Agents Apply On Or Off the Exchange Apply in Under 5 Minutes
2017 Plans
BCBSTX 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 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.
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. | ||
Ryan Kennelly authorized agent for Blue Cross and Blue Shield of Texas Blue Cross and Blue Shield of Texas: A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
Blue Cross and Blue Shield of Texas
- 2023 Plan Guide
- Find Plans & Get Quotes
- Paper Application
- Online Application
- Medicare Supplement Application
Individual Plan Guides
Quotes/Talk to an Agent
(312) 726-6565
Find What Plans Your Doctor Accepts
Find Every Plan In Your Area Calculate Your Subsidy Live Chat Our Agents Apply On Or Off the Exchange Apply in Under 5 Minutes