Blue Advantage Gold HMO℠ 603 – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$5,000 per person $10,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	$45 copay
Specialist visit	40% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay
Emergency room	$950 copay after deductible, 40% coinsurance after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	$850 copay per Stay after deductible, 40% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	$600 copay after deductible, 20% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	40% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$850 copay after deductible, 40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	No charge
Brand	$50 copay
Non-preferred Brand	35% coinsurance after deductible
Specialty	45% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	40% coinsurance after deductible
Psychiatric hospital stay	$850 copay per Stay after deductible, 40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbstx.com/sbc/ind/sbc-ghsa27bavitxp-tx-2024.pdf
Drug and medication plan formulary	https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_TX_6T_HIM.pdf
Search doctor list	https://my.providerfinderonline.com/?ci=tx-blueadvantage-retail&corp_code=TX