Blue Cross Blue Shield Blue Advantage Silver HMO 004 (Texas)

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

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.

Deductible (Individual) $3,000
Deductible (Family) $9,000
Coinsurance 20%
Out of Pocket Maximum (Individual) $6,350
Out of Pocket Maximum (Family) $12,700

Doctors Visits

Primary Care Visit $35
Specialist Visit $55
In Patient Hospital Services $250 Copay per Stay and 20% Coin
Emergency Room Services $500 Copay and 20% Coinsurance a

Tests and Imaging

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

Other

Mental / Behavioral Health $35 copay
Rehabilitative Speech Therapy 20% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance
Outpatient Facility $200 copay
Outpatient Surgery 20% coinsurance

Prescription Drugs

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

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
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.

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