Blue Advantage Gold HMO℠ 603

Health Insurance Plan Details (2024 Plan)

by Blue Cross Blue Shield of Texas

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$1,500 /yr
Max Out-of-Pocket
$5,000 /yr

Details

Deductible (per individual) $1,500 /yr
Deductible (per family) $3,000 /yr
Max Out-of-Pocket (per individual) $5,000 /yr
Max Out-of-Pocket (per family) $10,000 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $45 Copay
Specialist Visit 40% Coinsurance after deductible
Emergency Room $950 Copay with deductible and 40% Coinsurance after deductible
Inpatient Facility $850 Copay per Stay with deductible and 40% Coinsurance after deductible
Inpatient Physician 40% Coinsurance after deductible
Drug Costs
Generic Drugs No Charge
Preferred Brand Drugs $50 Copay
Non-preferred Brand Drugs 35% Coinsurance after deductible
Specialty Drugs 45% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

Insurance Carrier Disclaimer

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

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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