Blue Cross Blue Shield of Texas health insurance plan with the Plan ID 33602TX0460694. The plan is called Blue Advantage Silver HMO℠ 205.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.31% (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 5.69% 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 | 33602TX0460694 | ||||||||||||||||||
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Health Insurance Plan Year | 2022 | ||||||||||||||||||
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 | 33602TX0460694-06 | ||||||||||||||||||
Provider Network(s) | ['TXN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 33602TX0460694-00 Standard On Exchange Plan - 33602TX0460694-01 Open to Indians below 300% FPL - 33602TX0460694-02 Open to Indians above 300% FPL - 33602TX0460694-03 73% AV Silver Plan - 33602TX0460694-04 |
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Last Plan Update Date | Sat, 06 Nov 2021 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.94307044 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2022 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | 94% AV Level Silver Plan |
Dental Only Plan | No |
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 |
First Tier Utilization | 85% |
Formulary ID | TXF017 |
Formulary URL | URL |
HIOS Product ID | 33602TX046 |
Import Date | 11/6/2021 0:05 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
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 | Silver |
Multiple In Network Tiers | Yes |
National Network | No |
Network ID | TXN001 |
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 | 1/1/2022 |
Plan ID (Standard Component ID with Variant) | 33602TX0460694-06 |
Plan Marketing Name | Blue Advantage Silver HMO℠ 205 |
Plan Type | HMO |
Plan Variant Marketing Name | Blue Advantage Silver HMO℠ 205 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $900 |
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 | $900 |
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 | $500 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 15% |
Service Area ID | TXS161 |
Source Name | HIOS |
Specialist Requiring a Referral | Referrals are required for some services. Please check with your Medical Group for details. |
Plan ID | 33602TX0460694 |
State Code | TX |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
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, In Network (Tier 2), Default Coinsurance | 30.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $2700 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $900 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $900 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $2700 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $900 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $900 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
Unique Plan Design | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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