Blue Cross Blue Shield Blue Choice Silver PPO 003 TX

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

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) $6,000 $12,000
Deductible (Family) $12,700 $25,400
Coinsurance $0 20%
Out of Pocket Maximum (Individual) $6,000 $12,000
Out of Pocket Maximum (Family) $12,700 $25,400
Services In Network Out of Network
Primary Care Visit $30 20% coinsurance
Specialist Visit $50 20% coinsurance
In Patient Hospital Services $250 Copay per Stay 20% coinsurance
Emergency Room Services $500 $500 copay
Mental / Behavioral Health $30 copay 20% coinsurance
Imaging (CT/PET Scans, MRIs) $0 20% coinsurance
Rehabilitative Speech Therapy $0 20% coinsurance
Rehabilitative Occupational & Physical Therapy $0 20% coinsurance
Preventative Care $0 20% coinsurance
Laboratory Outpatient and Professional Services $0 20% coinsurance
X-ray and Diagnostic Imaging $0 20% coinsurance
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.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $5,000.00
Deductible (Family) $10,400.00
Out of Pocket Maximum (Individual) $5,000.00
Out of Pocket Maximum (Family) $10,400.00
Services In Network Out of Network
Primary Care Physician $30
Specialists $50
Emergency Room $500
Inpatient Facility $250 Copay per Stay
Inpatient Physician No Charge
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) $1,500.00
Deductible (Family) $4,500.00
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 $30
Specialists $50
Emergency Room $500
Inpatient Facility $250 Copay per Stay
Inpatient Physician No Charge
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) $500.00
Deductible (Family) $1,500.0
Out of Pocket Maximum (Individual) $500.00
Out of Pocket Maximum (Family) $1,500.00
Services In Network Out of Network
Primary Care Physician $30
Specialists $50
Emergency Room $500
Inpatient Facility $250 Copay per Stay
Inpatient Physician No Charge
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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This tool is for research purposes only. The numbers shown are estimates based on the information you have provided and our best efforts to provide accurate data. We try to keep the information up to date however we cannot make warranties about the accuracy of our information. We advise that users confirm any research with the respective health insurance companies and health exchanges.