Blue Advantage Plus Gold℠ Standard - 33602TX0870148 Health Insurance Plan
Blue Cross Blue Shield of Texas health insurance plan with the Plan ID 33602TX0870148. The plan is called Blue Advantage Plus Gold℠ Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 33602TX0870148 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Texas | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 33602TX0870148-02 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED BLUE-ADVANTAGE-HMO PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 33602TX0870148-00 Standard On Exchange Plan - 33602TX0870148-01 |
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| Last Plan Update Date | Wed, 23 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Blue Advantage Plus Gold℠ Standard Health Insurance Plan, 33602TX0870148-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
When services are provided in an office setting, cost shares may vary. Please see benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Benefit Period Muscle manipulations included in Rehabilitation and Habilitation limits. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Cosmetic Surgery
Except when medically necessary. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dialysis
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period All frames will first apply towards the allowance. Discount will apply on remaining balance, after the allowance. See benefit book for details |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Generic Drugs
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Certain generic drugs may have a higher cost share amount than is listed on this page. When prescription drugs are bought from an out of network pharmacy additional charges may apply. See benefit book for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Benefit Period Limit includes muscle manipulations. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Coverage is limited to 1 hearing aid per ear every 36 month |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hospice Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Imaging (CT/PET Scans, MRIs)
CT scan for heart disease screening. Maximum 1 visit for EDT per every 5 years. Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Laboratory Outpatient and Professional Services
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Member cost share may increase when using a setting other than office. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Outpatient Services
Member cost share may increase when using a setting other than office. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Non-Preferred Brand Drugs
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Nutritional Counseling
Covered for Preventive and Diabetes services only. |
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Limit includes muscle manipulations. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preferred Brand Drugs
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Prenatal and Postnatal Care
First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Private-Duty Nursing
Exclusions: Not covered unless medically necessary. |
NO | ||
| Prosthetic Devices
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Radiation
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Reconstructive Surgery
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Benefit Period Limit includes muscle manipulations. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Speech Therapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period When purchasing Out of Network, reimbursements are available. See benefit book for details. |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
Covered when medically necessary |
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Days per Benefit Period |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialty Drugs
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. Certain specialty drugs may have a higher cost share amount than is listed on this page. If prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Abuse Disorder Inpatient Services
Member cost share may increase when using a setting other than office. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Abuse Disorder Outpatient Services
Member cost share may increase when using a setting other than office. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Transplant
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Excludes any non-surgical (dental restorations, orthodontics, or physical therapy) or non-diagnostic services or supplies (oral appliances, oral splints, oral orthotics, devices, or prosthetics) provided for the treatment of the temporomandibular joint and all adjacent or related muscles and nerves. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| X-rays and Diagnostic Imaging
Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Blue Advantage Plus Gold℠ Standard Health Insurance Plan Variant 33602TX0870148-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | TXF010 |
| Formulary URL | URL |
| HIOS Product ID | 33602TX087 |
| Import Date | 2024-10-23 01:02:32 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 33602 |
| Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of Texas |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | TXN009 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | No coverage for any services, supplies or drugs received by a Member outside of the United States, except for Emergency Care |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage outside our service area is available for Emergency and Urgent Care services only. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 33602TX0870148-02 |
| Plan Marketing Name | Blue Advantage Plus Gold℠ Standard |
| Plan Type | POS |
| Plan Variant Marketing Name | Blue Advantage Plus Gold℠ Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS089 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Referrals are required for some services. Please check with your Medical Group for details. |
| Plan ID | 33602TX0870148 |
| State Code | TX |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Advantage Plus Gold℠ Standard Health Insurance Plan, 33602TX0870148
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Advantage Plus Gold℠ Standard, 33602TX0870148 Health Insurance Plan, 33602TX0870148
-
Does Blue Advantage Plus Gold℠ Standard Health Insurance Plan, 33602TX0870148 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (33602TX0870148) Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs?
Does (33602TX0870148) Health Insurance Plan, Variant (33602TX0870148-02) have Out Of Country Coverage?
Does (33602TX0870148) Health Insurance Plan, Variant (33602TX0870148-02) have Out of Service Area Coverage?
Does (33602TX0870148) Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs?
Does Blue Advantage Plus Gold℠ Standard Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs for Asthma?
Does Blue Advantage Plus Gold℠ Standard Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs for Heart disease?
Does Blue Advantage Plus Gold℠ Standard Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs for Depression?
Does Blue Advantage Plus Gold℠ Standard Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs for Diabetes?
Does Blue Advantage Plus Gold℠ Standard Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Advantage Plus Gold℠ Standard Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs for Low back pain?
Does Blue Advantage Plus Gold℠ Standard Health Insurance Plan, Variant (33602TX0870148-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API