Blue Cross Blue Shield Blue Advantage Bronze HMO 005 (Texas)

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Company Blue Cross Blue Shield of Texas
Plan Year 2014
State Texas
Metal Tier Bronze
Plan Type HMO
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Cost Sharing Benefits (In Network)

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.

Deductible (Individual) $5,000
Deductible (Family) $12,700
Coinsurance 20%
Out of Pocket Maximum (Individual) $6,250
Out of Pocket Maximum (Family) $12,700

Doctors Visits

Primary Care Visit 20% Coinsurance after deductible
Specialist Visit 20% Coinsurance after deductible
In Patient Hospital Services 20% Coinsurance after deductible
Emergency Room Services 20% Coinsurance after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) $250 copay
Laboratory Outpatient and Professional Services 20% coinsurance
X-ray and Diagnostic Imaging 20% coinsurance


Mental / Behavioral Health 20% coinsurance
Rehabilitative Speech Therapy 20% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance
Outpatient Facility $0
Outpatient Surgery $0

Prescription Drugs

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.

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