HDHP
Medical benefits are provided through Blue Cross Blue Shield of Texas (BCBSTX) and include PPO and HDHP with biweekly premiums, in-network and out-of-network cost.
HDHP
Plan Details
Carrier
Blue Cross Blue Shield of Texas (BCBSTX)
Plan Type
HDHP
Out-of-Network Coverage
Yes
HSA Eligible
Yes
FSA Eligible
Limited Purpose FSA
Premiums
BIWEEKLY CONTRIBUTIONS
Employee only
- Biweekly Contribution
- $79.05
Employee + spouse
- Biweekly Contribution
- $142.97
Employee + child(ren)
- Biweekly Contribution
- $120.88
Employee + family
- Biweekly Contribution
- $199.15
Deductible, Out-of-Pocket & Coinsurance
Annual deductible - Individual
- In-network
- $3,500
- Out-of-network
- $5,600
Annual deductible - Family
- In-network
- $7,000
- Out-of-network
- $11,200
Coinsurance (you pay)
- In-network
- 20%*
- Out-of-network
- 40%*
Annual out-of-pocket maximum (maximum includes deductible) - Individual
- In-network
- $5,000
- Out-of-network
- $10,000
Annual out-of-pocket maximum (maximum includes deductible) - Family
- In-network
- $7,000
- Out-of-network
- $14,000
*After deductible
Covered Services
Preventive care
- In-network
- 100% No Deductible
- Out-of-network
- 100% No Deductible
Physician office
- In-network
- 20%*
- Out-of-network
- 40%*
Specialist office
- In-network
- 20%*
- Out-of-network
- 40%*
Urgent care
- In-network
- 20%*
- Out-of-network
- 40%*
Emergency room
- In-network
- Deductible + 20%
- Out-of-network
- Deductible + 20%
Telemedicine
- In-network
- 20%*
- Out-of-network
- N/A
X-ray/lab
- In-network
- 20%*
- Out-of-network
- 40%*
Outpatient/Inpatient**
- In-network
- 20%*
- Out-of-network
- 40%*
*After deductible
** Blue Distinction Center Providers = 10% Coinsurance after deductible
Retail RX (30-DAY SUPPLY)
Preventive - Generic
- In-network
- $10
- Out-of-network
- 40%*
Preventive - Preferred brand
- In-network
- $50
- Out-of-network
- 40%*
Preventive - Non-preferred brand
- In-network
- $100
- Out-of-network
- 40%*
Preventive - Specialty
- In-network
- $150
- Out-of-network
- 40%*
Non-preventive - Generic
- In-network
- 20%*
- Out-of-network
- 40%*
Non-preventive - Preferred brand
- In-network
- 20%*
- Out-of-network
- 40%*
Non-preventive - Non-preferred brand
- In-network
- 20%*
- Out-of-network
- 40%*
Non-preventive - Specialty
- In-network
- 20%*
- Out-of-network
- 40%*
*After deductible
Mail Order RX (90-DAY SUPPLY)
Preventive - Generic
- In-network
- $20
- Out-of-network
- 40%*
Preventive - Preferred brand
- In-network
- $100
- Out-of-network
- 40%*
Preventive - Non-preferred brand
- In-network
- $200
- Out-of-network
- 40%*
Preventive - Specialty
- In-network
- $300
- Out-of-network
- 40%*
Non-preventive - Generic
- In-network
- 20%*
- Out-of-network
- 40%*
Non-preventive - Preferred brand
- In-network
- 20%*
- Out-of-network
- 40%*
Non-preventive - Non-preferred brand
- In-network
- 20%*
- Out-of-network
- 40%*
Non-preventive - Specialty
- In-network
- 20%*
- Out-of-network
- 40%*
*After deductible
Plan Notes
- You’ll pay less in premiums. (Think less money from your paycheck.)
- You’ll pay for the full cost of non-preventive medical services until you reach your deductible.
- You may also use your Health Savings Account (HSA) to pay for Healthcare expenses.
- If you expect to mostly use preventive care (which is covered), this plan could be for you.
- You must call BCBS Health Advocacy Solutions to receive approval for MRI and CT Scan imaging, or you will receive a $100 penalty fee.