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Blue - Blue Advantage Security HMO? 200
Texas, 2019
Plan Type
HMO
Metal Tier
Catastrophic
Out of Pocket Maximum
$7,900
Deductible
$7,900
Emergency Room Care: No charge after deductible
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) | $7,900 |
|---|---|
| Deductible (Family) | $15,800 |
| Coinsurance | Not applicable |
| Out of Pocket Maximum (Individual) | $7,900 |
| Out of Pocket Maximum (Family) | $15,800 |
Doctor Visits
| Primary Care Visit | No charge after deductible |
|---|---|
| Specialist Visit | No charge after deductible |
| Inpatient Facility | No charge after deductible |
| Inpatient Physician | No charge after deductible |
| Emergency Room Services | No charge after deductible |
Tests and Imaging
| Imaging (CT/PET Scans, MRIs) | No charge after deductible |
|---|---|
| Laboratory Outpatient and Professional Services | No charge after deductible |
| X-Ray and Diagnostic Imaging | No charge after deductible |
Health Management Programs
| Asthma | Available |
|---|---|
| Depression | Available |
| Diabetes | Available |
| Heart Disease | Available |
| High Blood Pressure / High Cholesterol | Available |
| Lower Back Pain | Available |
| Pain Management | Available |
| Pregnancy | Available |
| Weight Loss | Not available |
Other
| Mental / Behavioral Health Inpatient | No charge after deductible |
|---|---|
| Mental / Behavioral Health Outpatient | No charge after deductible |
| Rehabilitative Speech Therapy | No charge after deductible |
| Rehabilitative Occupational & Physical Therapy | No charge after deductible |
| Outpatient Facility | No charge after deductible |
| Outpatient Surgery | No charge after deductible |
Prescription Drugs
| Generic Rx | No charge after deductible |
|---|---|
| Preferred Brand Rx | No charge after deductible |
| Non Preferred Brand Rx | No charge after deductible |
| Specialty Drugs | No charge after deductible |
Other Plans in Texas
| Plan | Deductible | Coinsurance | Out of Pocket |
|---|---|---|---|
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Silver HMO? 205 - Two $25 PCP Visits | Deductible $1,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 301 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Silver? 202 | Deductible $1,100 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 303 | Deductible $3,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Gold HMO? 206 - Three $30 PCP Visits | Deductible $350 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Bronze? 305 | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Security HMO? 200 | Deductible $7,900 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Plus Gold? 203 | Deductible $750 | Coinsurance Not applicable | Out of Pocket $7,900 |
| Plan Blue Advantage Bronze HMO? 204 - Two $40 PCP Visits | Deductible $6,000 | Coinsurance Not applicable | Out of Pocket $7,900 |