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Blue Advantage Gold HMO℠ 206
Health Insurance Plan Details (2024 Plan)
by Blue Cross Blue Shield of Texas
Monthly Premium
HMO
$ubsidy
Gold
- Deductible
- $750 /yr
- Max Out-of-Pocket
- $9,450 /yr
Details
Deductible (per individual) | $750 /yr |
Deductible (per family) | $1,500 /yr |
Max Out-of-Pocket (per individual) | $9,450 /yr |
Max Out-of-Pocket (per family) | $18,900 /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 |
Out-of-Pocket Costs
Preventive Care | No Charge |
Primary Care Visit | $30 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 |
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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