Blue Cross Blue Shield Blue Choice Bronze PPO 005 TX

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

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 $10,000
Deductible (Family) $12,700 $25,400
Coinsurance 20% 40%
Out of Pocket Maximum (Individual) $6,250 $12,500
Out of Pocket Maximum (Family) $12,700 $25,400
Services In Network Out of Network
Primary Care Visit 20% Coinsurance after deductible 40% coinsurance
Specialist Visit 20% Coinsurance after deductible 40% coinsurance
In Patient Hospital Services 20% Coinsurance after deductible 40% coinsurance
Emergency Room Services 20% Coinsurance after deductible 20% coinsurance
Mental / Behavioral Health 20% coinsurance 40% coinsurance
Imaging (CT/PET Scans, MRIs) 20% coinsurance 40% coinsurance
Rehabilitative Speech Therapy 20% coinsurance 40% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance 40% coinsurance
Preventative Care $0 40% coinsurance
Laboratory Outpatient and Professional Services 20% coinsurance 40% coinsurance
X-ray and Diagnostic Imaging 20% coinsurance 40% coinsurance
Outpatient Facility 20% coinsurance 40% coinsurance
Outpatient Surgery 20% coinsurance 40% coinsurance
Prescription Drugs In Network Out of Network
Generic Rx 20% Coinsurance after deductible
Preferred Brand Rx 20% Coinsurance after deductible
Non Preferred Brand Rx 20% Coinsurance after deductible
Specialty Drugs 20% Coinsurance after deductible

Other Plans

Other plans that are available in the state.

Plan Name
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