Blue Advantage Silver HMO℠ 705 - 33602TX0460974 Health Insurance Plan

Blue Cross Blue Shield of Texas health insurance plan with the Plan ID 33602TX0460974. The plan is called Blue Advantage Silver HMO℠ 705.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.03% (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 12.97% 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 33602TX0460974
Health Insurance Plan Year 2024
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 33602TX0460974-05
Provider Network(s) NON-PREFERRED PREFERRED BLUE-ADVANTAGE-HMO
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Texas All US States
All 114239 184005
PCP 20551 24084
Allergy 71 80
OB/GYN 744 886
Dentists 249 432
Available Variants of the Health Plan

Standard Off Exchange Plan - 33602TX0460974-00

Standard On Exchange Plan - 33602TX0460974-01

Open to Indians below 300% FPL - 33602TX0460974-02

Open to Indians above 300% FPL - 33602TX0460974-03

73% AV Silver Plan - 33602TX0460974-04

87% AV Silver Plan - 33602TX0460974-05

94% AV Silver Plan - 33602TX0460974-06

Last Plan Update Date Fri, 01 Dec 2023 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Blue Advantage Silver HMO℠ 705 Health Insurance Plan, 33602TX0460974-05

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

30.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

30.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

30.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 35.0 Visit(s) per Benefit Period

Muscle manipulations included in Rehabilitation and Habilitation limits.

YES

30.00% Coinsurance after deductible

100.00%
Cosmetic Surgery

Covered only for the correction of congenital deformities in children, conditions resulting from accidental injuries, and reconstructive surgery following cancer surgery including prosthesis in the event of a mastectomy.

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

30.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

30.00% Coinsurance after deductible

100.00%
Dialysis
YES

30.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

30.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
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

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Provider-designated frames are covered. An allowance may apply to non-provider-designated frames. Coinsurance may apply to non-provider-designated frames on the remaining balance over the allowance. See benefit book for details.

YES

No Charge

100.00%
Gender Affirming Care
YES

30.00% Coinsurance after deductible

100.00%
Generic Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents 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. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details.

YES

$10.00

100.00%
Habilitation Services

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

YES

$20.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

Coverage is limited to 1 hearing aid per ear every 36 month

YES

30.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Benefit Period

YES

30.00% Coinsurance after deductible

100.00%
Hospice Services
YES

30.00% Coinsurance after deductible

100.00%
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. Member will be responsible for copay per imaging procedure before and after meeting the plan deductible. The remainder of the eligible charge will not be subject to plan deductible and coinsurance. See benefit book for details.

YES

30.00% Coinsurance after deductible

100.00%
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

$50.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

30.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. Member will be responsible for copay per laboratory outpatient or service procedure before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

YES

30.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$20.00

100.00%
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, Impotency, OTC Equivalents and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Out of Network Pharmacy coverage is only available in emergency situations. 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

$60.00 Copay after deductible

100.00%
Nutritional Counseling

Covered for Preventive and Diabetes services only.

NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$40.00

100.00%
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

30.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

YES

$20.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Out of Network Pharmacy coverage is only available in emergency situations. 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

$20.00

100.00%
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

$20.00

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$20.00

100.00%
Private-Duty Nursing

Exclusions: Not covered unless medically necessary.

NO
Prosthetic Devices
YES

30.00% Coinsurance after deductible

100.00%
Radiation
YES

30.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

YES

$20.00

100.00%
Rehabilitative Speech Therapy
YES

$20.00

100.00%
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

No Charge

100.00%
Routine Foot Care

Covered when medically necessary

NO
Skilled Nursing Facility

Limit: 25.0 Days per Benefit Period

YES

30.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$40.00

100.00%
Specialty Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents 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. Out of Network Pharmacy coverage is only available in emergency situations. 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

$250.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$20.00

100.00%
Transplant
YES

30.00% Coinsurance after deductible

100.00%
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

30.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$30.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. Member will be responsible for copay per X-ray or diagnostic imaging procedure before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

YES

30.00% Coinsurance after deductible

100.00%

Blue Advantage Silver HMO℠ 705 Health Insurance Plan Variant 33602TX0460974-05 Attributes

Plan Attribute Value
AV Calculator Output Number 0.87028256655624
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type 87% AV Level Silver Plan
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 TXF030
Formulary URL URL
HIOS Product ID 33602TX046
Import Date 2023-12-01 01:01:56
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 No
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 2024-01-01
Plan ID (Standard Component ID with Variant) 33602TX0460974-05
Plan Marketing Name Blue Advantage Silver HMO℠ 705
Plan Type HMO
Plan Variant Marketing Name Blue Advantage Silver HMO℠ 705
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2300
SBC Scenario, Having a Baby, Copayment $20
SBC Scenario, Having a Baby, Deductible $700
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $60
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $700
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $400
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TXS221
Source Name HIOS
Specialist Requiring a Referral Referrals are required for some services. Please check with your Medical Group for details.
Plan ID 33602TX0460974
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 $1400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $700 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $700
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 $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $3,000
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

Copay & Coinsurance of Blue Advantage Silver HMO℠ 705 Health Insurance Plan, 33602TX0460974

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue Advantage Silver HMO℠ 705, 33602TX0460974 Health Insurance Plan, 33602TX0460974

  • Does Blue Advantage Silver HMO℠ 705 Health Insurance Plan, 33602TX0460974 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (33602TX0460974) Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (33602TX0460974) Health Insurance Plan, Variant (33602TX0460974-05) have Out Of Country Coverage?

    Yes. Details: No coverage for any services, supplies or drugs received by a Member outside of the United States, except for Emergency Care

    Does (33602TX0460974) Health Insurance Plan, Variant (33602TX0460974-05) have Out of Service Area Coverage?

    Yes. Details: Coverage outside our service area is available for Emergency and Urgent Care services only.

    Does (33602TX0460974) Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Blue Advantage Silver HMO℠ 705 Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs for Asthma?

    Yes, the Blue Advantage Silver HMO℠ 705 Health Insurance Plan Variant 33602TX0460974-05 offers Disease Management Program for Asthma.

    Does Blue Advantage Silver HMO℠ 705 Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs for Heart disease?

    Yes, the Blue Advantage Silver HMO℠ 705 Health Insurance Plan Variant 33602TX0460974-05 offers Disease Management Program for Heart disease.

    Does Blue Advantage Silver HMO℠ 705 Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs for Depression?

    Yes, the Blue Advantage Silver HMO℠ 705 Health Insurance Plan Variant 33602TX0460974-05 offers Disease Management Program for Depression.

    Does Blue Advantage Silver HMO℠ 705 Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs for Diabetes?

    Yes, the Blue Advantage Silver HMO℠ 705 Health Insurance Plan Variant 33602TX0460974-05 offers Disease Management Program for Diabetes.

    Does Blue Advantage Silver HMO℠ 705 Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Advantage Silver HMO℠ 705 Health Insurance Plan Variant 33602TX0460974-05 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Advantage Silver HMO℠ 705 Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs for Low back pain?

    Yes, the Blue Advantage Silver HMO℠ 705 Health Insurance Plan Variant 33602TX0460974-05 offers Disease Management Program for Low back pain.

    Does Blue Advantage Silver HMO℠ 705 Health Insurance Plan, Variant (33602TX0460974-05) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Advantage Silver HMO℠ 705 Health Insurance Plan Variant 33602TX0460974-05 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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