Blue Cross Blue Shield Blue Advantage Bronze HMO 005 TX

Plan Information
Company Blue Cross Blue Shield of Texas
State TX
Metal Tier Bronze
Plan Type HMO

Cost Sharing Benefits

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $5,000 $0
Deductible (Family) $12,700 $0
Coinsurance 20% $0
Out of Pocket Maximum (Individual) $6,250 $0
Out of Pocket Maximum (Family) $12,700 $0
Services In Network Out of Network
Primary Care Visit 20% Coinsurance after deductible $0
Specialist Visit 20% Coinsurance after deductible $0
In Patient Hospital Services 20% Coinsurance after deductible $0
Emergency Room Services 20% Coinsurance after deductible 20% coinsurance
Mental / Behavioral Health 20% coinsurance $0
Imaging (CT/PET Scans, MRIs) $250 copay $0
Rehabilitative Speech Therapy 20% coinsurance $0
Rehabilitative Occupational & Physical Therapy 20% coinsurance $0
Preventative Care $0 $0
Laboratory Outpatient and Professional Services 20% coinsurance $0
X-ray and Diagnostic Imaging 20% coinsurance $0
Outpatient Facility $0 $0
Outpatient Surgery $0 $0
Prescription Drugs In Network Out of Network
Generic Rx 10% Coinsurance after deductible
Preferred Brand Rx 20% Coinsurance after deductible
Non Preferred Brand Rx 30% Coinsurance after deductible
Specialty Drugs 40% Coinsurance after deductible

Other Plans

Other plans that are available in the state.

Plan Name
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