Blue Cross Blue Shield Plan Guide for Texas 2024

All You Need to Know About BCBSTX Plans for 2024

Shopping for health insurance in Texas doesn’t have to be complicated. When you find an insurance company, you need to select a plan. However, that can be a confusing process. We at CoverMile are here to assist you in understanding what Blue Cross Blue Shield of Texas plans offer and to guide you through what their coverage chart means to you.

Health Insurance Terms to Understand

Before we begin, let’s provide a few brief definitions behind some of the terms you will see frequently but may not completely understand. This will better aid you in selecting the best health coverage that fits your situation.

Deductible – This is the big one. A deductible is the amount you will pay out of pocket before your insurance kicks in. Blue Cross Blue Shield of TX has deductibles from $0 up to $9450, depending on your plan choice. Deductibles are based on the calendar year and refresh each year. They also determine how much you will pay overall. The higher your deductible, the lower your premium; the lower your deductible, the higher your premium. The deductible is broken down into two parts:         

            Individual: This is the per-person deductible.

            Family: This is the deductible for the entire family.

Your Summary of Benefits will often reflect this in fraction form. For instance, $750 Individual/$1500 Family. Each family member has their own $750 out-of-pocket expense to reach. You can read more about deductibles through the link above.

Coinsurance – Coinsurance is where the insurance kicks in. It is cost sharing between you and the insurance company, usually reflected as a percentage. It is generally listed as “50% coinsurance” or just “50%”, whatever your policy’s coverage level is. This is the portion you will pay until your out-of-pocket max is reached. It refreshes each year. Understand the on a Summary of Benefits, when you see this number, it means after your deductible is met, unless otherwise specified.

Out-of-Pocket Max – All insurances have a failsafe. It is called the out-of-pocket max. It is usually double the individual deductible. (7500/15000) This is to help those with high medical costs due to medical conditions who visit the doctor regularly. When you reach your individual deductible, pay through your coinsurance, and then reach the out-of-pocket maximum specified in your policy, your insurance begins to pay 100 percent of medical expenses for that individual. This continues until the calendar year rolls over. Like your deductible, this portion has an individual and family stipulation. Once your out-of-policy max is reached, it will apply to all persons on the policy regardless of if their individual deductible has been met.

Primary Care Physician – Your Primary Care Physician, who you will also see abbreviated as PCP, is the main doctor you visit for your medical care. With BCBS of TX, an HMO, you are required to coordinate all treatment through them. If you need to see a Specialist, your first stop needs to be your PCP. Then, with their recommendation and BCBS of Texas approval, you will be able to see the specialist and have tests done.

Copay – Copays are the amount you pay the doctor or facility for your visit. This can be a flat dollar amount or a percentage. It can vary by plan. Keep in mind this is for the office visit alone, not the treatment you receive. However, some treatments can be included in an office visit, like a well checkup or immunizations; see your medical plan for details.

Now that you know the basics of health insurance, let’s get into the plans Blue Cross Blue Shield of Texas has to offer.

Blue Cross Blue Shield of Texas and the Affordable Care Act

Blue Cross Blue Shield of Texas offers plans as part of the Affordable Care Act. They are broken down into Bronze, Silver, and Gold metal tier levels. Most of their plans are offered on the Marketplace website; to view their full selection, you can visit the BCBS of TX website.

Below, we are listing a variety of plans BCBS of TX offers. For the sake of space, we are only listing a few plans based on price, deductible, and coinsurance. Also, to simplify our table, you will see the Individual and Family deductibles and out-of-pocket max expressed as a fraction. The first is your Individual, and the second is your Family. Also, be aware that these numbers are for in-network doctors and facilities.

Blue Cross Blue Shield Bronze

BCBS of TX has nine Bronze metal plans. Each offers a different deductible, coinsurance, and out-of-pocket max. Bronze plans are best for those who are single, healthy, and don’t visit the doctor that often. If you only see a doctor for a cold, your annual checkup, or immunizations, then this metal level may be best for you.

Bronze	Blue Advantage Plus – 303	Blue Advantage HMO – 204	Blue Advantage HMO -707	My Blue Health – 402
Deducible	$4500/$9000	$6000/$12,000	$7500/$15,000	$7400/$14,800
Coinsurance	40%	50%	50%	50%
Out-of-Pocket Max	$7500/$15,000	$9450/$18,900	$9400/$18,800	$9450/$18,900
Primary Care Visit	$80	$45	$50 copay	$0 for PCP – $30 all others
Specialist Visit	50%	50%	$100 copay	50%
Emergency Room	$950/occurrence deductible, then 50%	$950/occurrence deductible, then 50%	50%	$950/occurrence deductible, then 50%
Urgent Care	$120 copay	$60 copay	$75 copay	$0 first two, then $30
Inpatient Hospital	$850/occurrence deductible, then 50%	$850/occurrence deductible, then 50%	50%	$850/occurrence deductible, then 50%
Outpatient Hospital	$600/occurrence deductible, then 50%	$600/occurrence deductible, then 50%	50%	$600/occurrence deductible, then 50%
Prescription (Pharmacy)	$5/$15/$130/ 35%/45%/50%	$5/$15/30%/35%/ 45%/50%*	$25/$50/$100/$500*	$10/$20/30%/ 35%/45%/50%

*Prescriptions are Preferred and Non-Preferred Generic/Preferred and Non-Preferred Brand/Preferred and Non-Preferred Specialty

Blue Cross Blue Shield Silver

BCBS of TX offers eleven Silver metal plans. Silver plans are the most popular sold through the Affordable Care Act Marketplace. This is primarily because this is the level that those who qualify for cost-sharing reductions must apply for. Those who are eligible for the premium tax credit also apply for this level to maximize benefits, but tax credits can be credited to any metal level.

Silver	Blue Advantage Plus – 202	Blue Advantage Plus HMO – 705	Blue Advantage HMO – 205	My Blue Health – 405
Deducible	$1500/$3000	$5900/$11,800	$1950/$3900	$2250/$4500
Coinsurance	50%	40%	50%	40%
Out-of-Pocket Max	$9450/$18,900	$9100/$18,200	$9450/$18,900	$9450/$18,900
Primary Care Visit	$25 copay	$40 copay	$15 copay	$0 for PCP – $30 all others
Specialist Visit	50%	$80 copay	50%	40%
Emergency Room	$950/occurrence deductible, then 50%	40%	$950/occurrence deductible, then 50%	$950/occurrence deductible plus 40%
Urgent Care	$40 copay	$60 copay	$25 copay	$0 first two, then $30
Inpatient Hospital	$850/occurrence deductible, then 50%	40%	$850/occurrence deductible, then 50%	$850/occurrence deductible plus 40%
Outpatient Hospital	$600/occurrence deductible, then 50%	40%	$600/occurrence deductible, then 50%	$600/occurrence deductible, then 40%
Prescription (Pharmacy)	$5/$15/$30%/35%/ 45%/50%*	$20/$40/$80/ $350/40%/40%	$5/$15/30%/35% 45%/50%*	$5/$15/30%/35% 45%/50%*

*Prescriptions are Preferred and Non-Preferred Generic/Preferred and Non-Preferred Brand/Preferred and Non-Preferred Specialty

Blue Cross Blue Shield Gold

BCBS of TX Gold has nine plan offerings. Gold is the highest level of coverage. It generally provides the lowest deductibles, copays, and overall insurance costs. However, with the high level of coverage comes the price tag. They are best suited for those who visit the doctor frequently and expect to have advanced medical care in the near future.

Gold	Blue Advantage HMO – 206	Blue Advantage HMO – 603	Blue Advantage Plus-203	My Blue Health – 403
Deducible	$750/$1500	$1500/$4500	$850/$1700	$1000/$2000
Coinsurance	40%	40%	30%	30%
Out-of-Pocket Max	$9450/$18,900	$5000/$10,000	$9450/$18,900	$9450/$18,900
Primary Care Visit	$30 copay	$45 copay	$20 copay	$0 for PCP – $20 all others
Specialist Visit	40%	40%	$45 copay	30%
Emergency Room	$950/occurrence deductible, then 40%	$950/occurrence deductible, then 40%	$950/occurrence deductible, then 30%	$950/occurrence deductible, then 30%
Urgent Care	$45 copay	$60 copay	$45 copay	$0 first two, then $30
Inpatient Hospital	$850/occurrence deductible, then 40%	$850/occurrence deductible, then 40%	$850/occurrence deductible, then 30%	$850/occurrence deductible, then 30%
Outpatient Hospital	$600/occurrence deductible, then 40%	$600/occurrence deductible, then 40%	30%	$300/occurrence deductible, then 30%
Prescription (Pharmacy)	$0/$10/$50/35%/ 45%/50%*	$0/$10/$50/35%/ 45%/50%*	$0/$10/$50/35%/ 45%/50%*	$10/$25/35%/40% 45%/50%

*Prescriptions are Preferred and Non-Preferred Generic/Preferred and Non-Preferred Brand/Preferred and Non-Preferred Specialty

***MyBlue Health Plans are only available to select counties. These include Bexar, Cameron, Collin, Dallas, Denton, El Paso, Harris, Hidalgo, Tarrant, Travis, and Williamson.

Finding a Doctor or Facility in Your Network

Through Blue Cross Blue Shield of Texas, you are required to remain in-network to receive the highest level of coverage. You may use out-of-network doctors and facilities, but you would first need BCBS of TX permission, and there would need to be a medical necessity to the visit. Also, you would not have the same coverage you would if you saw a preferred provider. For instance,

• Let’s say you have a Gold Advantage plan. Your copay to see an in-network primary care physician is $20. If you choose to see an out-of-network doctor, your benefit changes to 50% coinsurance for the visit. So, if your doctor charges $100, that $20 now becomes $50 just for the visit. If your doctor performed any screening or other treatment, that fee might increase.
• There are exceptions to the rule. If you are away from home and have a medical emergency and cannot get to an in-network facility, then you will not need to pay the out-of-network rate. However, it’s important to communicate your emergency to BCBS to ensure coverage is in place during your emergency visit.

BCBSTX allows you to search for doctors and facilities near you, see their ratings, and figure out cost estimates for treatment.

BCBSTX Comparison Charts:

As noted, the above are just a few available plans from each medal option. For a complete list of the Affordable Care Act plans, follow the links below.

Comparison Chart	Plan	Plan
BCBSTX Gold Plan	English	Spanish
BCBSTX Silver Plan	English	Spanish
BCBSTX Bronze Plan	English	Spanish

Benefit Notices:

Keep in mind that the above is a summary of highlights only.

–The benefits above represent what a member would pay. When a non-participating provider is used, benefits are reduced.

–You are required to pay all the costs up to the deductible amount before your plan begins to pay for covered services. What is shown is the per-person deductible and out-of-pocket maximum.

 –All percentages shown are of the allowable amount for covered services.

–Members may have lower out-of-pocket costs for non-emergency services at freestanding outpatient facilities than for out-of-pocket costs provided in a hospital setting.

–Prescription benefit coverage on some plans begins after the annual medical deductible has been met. This does not count copays. Retailers in the Preferred Pharmacy Network offer members medications a cost-share amount to differ the cost.

–Prescription drug payment level tiers: Preferred Generic / Non-Preferred Generic / Preferred Brand / Non-Preferred Brand /Preferred Specialty / Non-Preferred Specialty

–Four prescription drug payment level tiers: Generic / Preferred Brand / Non-Preferred Brand / Specialty

–On the Specialty level, one cannot receive more than a 30 supply, nor can they receive home delivery. Coverage for some drugs may also be limited.

–Blue365 is a member discount program. Shop and save on wellness products and services like hearing tests, eye exams, and dental services, as well as discounts on healthy lifestyle services.

Prescription Coverage with BCBSTX

With all Blue Cross Blue Shield of Texas Plans, customers receive Prescription coverage. Each plan has varied coverage and tiers. Each has these need-to-knows.

• Specialty Pharmacy Program – When you require specialty medication, to receive your maximum benefits, you must obtain your prescription from a Preferred Specialty Pharmacy provider.
• Member Pay the Difference – For most medications, you will be offered a generic substitute to save on prescription costs. If you choose to select the name brand, you will pay the difference for the name brand.
• Prior Authorization – In some cases, you may need prior approval to fill prescriptions from BCBS of TX. They may approve a more cost-effective drug instead of a suggested prescription.
• 90-day Supply – Depending on your drug benefit, you may be able to receive a 90-day supply of your prescription to save on your medication cost. One option is mail order RX through companies like Express Scripts.
• Step Therapy – With some prescriptions, BCBS of Texas requires other drugs to be offered before the recommended option is given.

BCBSTX can help you find a pharmacy in your area through its website.

At CoverMile, we desire to find the best health insurance in Texas that suits you and your family. We take the time to talk you through each plan, help you understand what Blue Cross Blue Shield of Texas offers, and assist you with signing up for Affordable Care Act insurance. Contact us today.