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    Individual Plan Comparison Chart: Participating Provider Coverage Shown

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    akula_rupesh
    This document provides a comparison of three individual health insurance plans - Blue Advantage Gold HMO, Blue Advantage Plus Gold, and Blue Advantage HMO - from Blue Cross Blue Shield of Texas. It outlines key details like deductibles, coinsurance, coverage for services, and prescription drug benefits. All plans provide coverage for preventive services and maternity care. Plan benefits and costs to members vary between the options.

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    Individual Plan Comparison Chart: Participating Provider Coverage Shown

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    akula_rupesh
    29 views1 page
    This document provides a comparison of three individual health insurance plans - Blue Advantage Gold HMO, Blue Advantage Plus Gold, and Blue Advantage HMO - from Blue Cross Blue Shield of Texas. It outlines key details like deductibles, coinsurance, coverage for services, and prescription drug benefits. All plans provide coverage for preventive services and maternity care. Plan benefits and costs to members vary between the options.

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    Original Title

    2016 Compare Gold Plans TX

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    This document provides a comparison of three individual health insurance plans - Blue Advantage Gold HMO, Blue Advantage Plus Gold, and Blue Advantage HMO - from Blue Cross Blue Shield of Texas. It outlines key details like deductibles, coinsurance, coverage for services, and prescription drug benefits. All plans provide coverage for preventive services and maternity care. Plan benefits and costs to members vary between the options.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views1 page

    Individual Plan Comparison Chart: Participating Provider Coverage Shown

    Uploaded by

    akula_rupesh
    This document provides a comparison of three individual health insurance plans - Blue Advantage Gold HMO, Blue Advantage Plus Gold, and Blue Advantage HMO - from Blue Cross Blue Shield of Texas. It outlines key details like deductibles, coinsurance, coverage for services, and prescription drug benefits. All plans provide coverage for preventive services and maternity care. Plan benefits and costs to members vary between the options.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    2016

    All plans from Blue Cross and Blue Shield of Texas (BCBSTX), a Division of Health
    Care Service Corporation, provide coverage for preventive services and maternity care.
    Please see your Summary of Benefits or visit bcbstx.com for more specific information.

    Individual Plan Comparison Chart


    Participating Provider Coverage Shown1

    Blue Advantage Gold HMOSM

    Gold

    Blue Advantage Plus GoldSM

    101

    Individual Deductible
    Coinsurance

    111

    101

    Plan Pays

    Member Pays

    Plan Pays

    Member Pays

    Plan Pays

    Member Pays

    $0

    $500

    $0

    $0

    $0

    $2,750

    70%

    30%

    100%

    no charge

    80%

    20%

    Out-of-Pocket Maximum
    (includes deductible)

    $5,250

    $6,850

    $3,500

    Office Visit (PCP / Specialist)

    100%

    $20 / $40

    100%

    $40 / $70

    100%

    $10 / $20

    Emergency Room / Outpatient


    Emergency Care (Physician and
    Hospital)

    70%2

    $500
    per occurrence deductible2

    100%

    $750
    per occurrence deductible2

    80%2

    $400
    per occurrence deductible2

    Urgent Care

    100%

    $75 copay

    100%

    $75 copay

    100%

    $75 copay

    Physician Medical / Surgical


    Services, Hospital Services and
    Hospital Diagnostic Testing
    (Inpatient / Outpatient Surgery)

    70%2

    $300 / $200
    per occurrence deductible2

    100%

    $1,500 copay per day / $500


    per occurrence deductible2 7

    80%2

    $200 / $200
    per occurrence deductible2

    Mental Illness Treatment


    and Substance Abuse Rehab
    (Inpatient / Outpatient)

    70%2

    $300 / $200
    per occurrence deductible2

    100%

    $1,500 copay per day / $500


    per occurrence deductible2 7

    80%2

    $200 / $200
    per occurrence deductible2

    Network

    Blue Advantage HMOSM

    Blue Advantage HMOSM

    HSA Eligible

    No

    Outpatient Prescription Drugs Preferred Pharmacy 4 5

    100% / 100% / 100% /


    100% / 70%2

    Outpatient Prescription Drugs Non-Preferred Pharmacy 4 5

    100% / 100% / 100% /


    100% / 70%2

    Prescription Drug Utilization


    Benefit Management Programs6

    Blue Advantage HMOSM

    No
    $0 / $10 / $50 / $100 / 30%2

    100% / 100% / 100% /


    100% / 70%2

    $5 / $15 / $60 / $110 / 30%2

    100% / 100% / 100% /


    100% / 70%2

    No
    $0 / $10 / $50 / $100 / 30%2

    100% / 100% / 100% /


    100% / 70%2

    $0 / $10 / $50 / $100 / 30%2

    $5 / $15 / $60 / $110 / 30%2

    100% / 100% / 100% /


    100% / 70%2

    $5 / $15 / $60 / $110 / 30%2

    Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider.
    Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost.
    Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSTX, and you may first need to try more clinically appropriate
    or cost-effective drugs.
    Mail-Order Program: You may receive a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit.

    1 Benefits reduced when non-preferred providers are used. This is a summary of benefit highlights only.

    4 Prescription benefit coverage starts after annual medical deductible has been met.

    2 Annual deductible and, if applicable, coinsurance still apply.

    5 Preferred Generics / Non-Preferred Generics / Preferred Brand / Non-Preferred Brand / Specialty

    3 As a reminder, a Health Savings Account (HSA) has tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice and nothing
    herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be
    used or relied on for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the
    transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax adviser regarding
    tax consequences of specific health insurance plans or products.

    6 Mail order is not available for Specialty tier drugs. Specialty tier is limited to a 30-day supply. Coverage limitations may apply to certain medications.
    7. Copay or deductible applies for certain services. See booklet for additional details.

    A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

    729821.1015

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