Blue Cross Blue Shield Blue Advantage Silver HMO 004 TX

These are the details for a 2014 Obamacare Plan. To see the available 2015 plans take a look at our plan comparison for the state of Texas. Compare Plans

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

Cost Sharing Benefits

These details are for the standard Silver plan. For reduced Cost Sharing versions scroll down below

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) $3,000 $0
Deductible (Family) $9,000 $0
Coinsurance 20% $0
Out of Pocket Maximum (Individual) $6,350 $0
Out of Pocket Maximum (Family) $12,700 $0
Services In Network Out of Network
Primary Care Visit $35 $0
Specialist Visit $55 $0
In Patient Hospital Services $250 Copay per Stay and 20% Coin $0
Emergency Room Services $500 Copay and 20% Coinsurance a 20% coinsurance after $500 copay/visit
Mental / Behavioral Health $35 copay $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
Prescription Drugs In Network Out of Network
Generic Rx No Charge
Preferred Brand Rx $50
Non Preferred Brand Rx $100
Specialty Drugs $150

73% Cost Sharing Benefits

Households with incomes between 200% to 250% of FPL qualify for the following cost sharing benefits for this silver plan. To understand how cost sharing reductions work and how they work for you see our article about Obamacare Cost Sharing Reduction Discounts

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $2,500.00
Deductible (Family) $7,500.00
Out of Pocket Maximum (Individual) $5,200.00
Out of Pocket Maximum (Family) $10,400.00
Services In Network Out of Network
Primary Care Physician $35
Specialists $55
Emergency Room $500 Copay and 20% Coinsurance a
Inpatient Facility $250 Copay per Stay and 20% Coin
Inpatient Physician 20% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx No Charge
Preferred Brand Rx $50
Non Preferred Brand Rx $100
Specialty Drugs $150

87% Cost Sharing Benefits

Households with incomes between 150% to 200% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $500.00
Deductible (Family) $1,500.00
Out of Pocket Maximum (Individual) $1,500.00
Out of Pocket Maximum (Family) $4,500.00
Services In Network Out of Network
Primary Care Physician $35
Specialists $55
Emergency Room $500 Copay and 20% Coinsurance a
Inpatient Facility $250 Copay per Stay and 20% Coin
Inpatient Physician 20% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx No Charge
Preferred Brand Rx $50
Non Preferred Brand Rx $100
Specialty Drugs $150

94% Cost Sharing Benefits

Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0.00
Deductible (Family) $0.00
Out of Pocket Maximum (Individual) $500.00
Out of Pocket Maximum (Family) $1,500.00
Services In Network Out of Network
Primary Care Physician $35
Specialists $55
Emergency Room $500 Copay and 20% Coinsurance a
Inpatient Facility $250 Copay per Stay and 20% Coin
Inpatient Physician 20% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx No Charge
Preferred Brand Rx $50
Non Preferred Brand Rx $100
Specialty Drugs $150

Other Plans

Other plans that are available in the state.

Plan Name
Blue Advantage Bronze HMO 005
Blue Advantage Bronze HMO 006
Blue Advantage Gold HMO 001
Blue Advantage Gold HMO 002
Blue Advantage Silver HMO 003
Blue Advantage Silver HMO 004
Blue Choice Bronze PPO 005
Blue Choice Bronze PPO 006
Blue Choice Gold PPO 001
Blue Choice Gold PPO 002
Blue Choice Silver PPO 003
Blue Choice Silver PPO 004
Blue Cross Blue Shield Basic 5, a Multi-State Plan
Blue Cross Blue Shield Premier 1, a Multi-State Plan
Blue Cross Blue Shield Premier 2, a Multi-State Plan
Blue Cross Blue Shield Solution 3, a Multi-State Plan
Blue Cross Blue Shield Solution 4, a Multi-State Plan
Blue Security Choice PPO 010
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