Form 729819.0615 - Silver Individual Plan Comparison Chart

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2016
All plans from Blue Cross and Blue Shield of Texas (BCBSTX), a Division of Health
Individual Plan Comparison Chart
Care Service Corporation, provide coverage for preventive services and maternity care.
Please see your Summary of Benefits or visit for more specific information.
Participating Provider Coverage Shown
1
Blue Advantage Silver HMO
Blue Advantage Plus Silver
SM
SM
Silver
102
103
102 - Three $0 PCP Visits
Plan Pays
Member Pays
Plan Pays
Member Pays
Plan Pays
Member Pays
Individual Deductible
$0
$2,000
$0
$3,500
$0
$3,250
Coinsurance
70%
30%
100%
No Charge
80%
20%
2
2
Out-of-Pocket Maximum
$6,850
$3,500
$6,850
(includes deductible)
First three PCP visits $0;
First three PCP visits $0;
Office Visit (PCP / Specialist)
100%
$40/ $60
100%
No Charge
2
then pays 80%
3
/ specialist 80%
then pays 20%
3
/ specialist 20%
Emergency Room / Outpatient
$600
$600
Emergency Care (Physician and
70%
100%
No Charge
80%
2
2
per occurrence deductible
per occurrence deductible
2
2
Hospital)
Urgent Care
100%
$75 copay
100%
No Charge
100%
$75 copay
Physician Medical / Surgical
Services, Hospital Services and
$500 / $300
$400 / $300
70%
100%
No Charge
80%
2
2
Hospital Diagnostic Testing
per occurrence deductible
per occurrence deductible
2
2
(Inpatient / Outpatient Surgery)
$400 / $300
Mental Illness Treatment
and Substance Abuse Rehab
70%
$500 / $300
100%
No Charge
80%
/ office visit paid at 100%
per occurrence deductible
/
2
2
2
2
(Inpatient / Outpatient)
$0 office visit copay
Network
Blue Advantage HMO
Blue Advantage HMO
SM
SM
HSA Eligible
3
No
Yes
No
Outpatient Prescription Drugs -
100% / 100% / 100% /
100% / 100% / 100% /
$0 / $10 / $50 / $100 / 30%
100%
No Charge
$0 / $10 / $50 / $100 / 30%
2
2
2
2
Preferred Pharmacy
4 5
100% / 70%
2
100% / 70%
2
Outpatient Prescription Drugs -
100% / 100% / 100% /
100% / 100% / 100% /
$5 / $15 / $60 / $110 / 30%
100%
No Charge
$5 / $15 / $60 / $110 / 30%
2
2
2
2
Non-Preferred Pharmacy
4 5
100% / 70%
2
100% / 70%
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.
Prescription Drug Utilization
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
Benefit Management Programs
6
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
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.
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.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
729819.0615

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