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.
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.
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.)
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.
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 |