Blue Advantage Silver HMO℠ 801 – HMO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$500 per person $500 per person
Out-of-pocket max	$3,150 per person $6,300 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	$70 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	No charge after deductible
Brand	20% coinsurance after deductible
Non-preferred Brand	30% coinsurance after deductible
Specialty	40% 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	$30 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbstx.com/sbc/ind/sbc-sh5d16bavitxp-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