Blue Cross Blue Shield of Texas (BCBSTX)
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 only
Premiums - Biweekly Contributions
| Coverage Tier | Biweekly Contribution |
|---|---|
| Employee Only | $79.05 |
| Employee + Spouse | $142.97 |
| Employee + Child(ren) | $120.88 |
| Employee + Family | $199.15 |
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
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Annual Deductible - Individual | $3,500 | $5,600 |
| Annual Deductible - Family | $7,000 | $11,200 |
| Coinsurance (You Pay) | 20%* | 40%* |
| Annual Out-of-Pocket Maximum - Individual | $5,000 | $10,000 |
| Annual Out-of-Pocket Maximum - Family | $7,000 | $14,000 |
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 - Individual
- In-Network
- $5,000
- Out-of-Network
- $10,000
Annual Out-of-Pocket Maximum - Family
- In-Network
- $7,000
- Out-of-Network
- $14,000
- * After deductible
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | 100% No Deductible | 100% No Deductible |
| Physician Office | 20%* | 40%* |
| Specialist Office | 20%* | 40%* |
| Urgent Care | 20%* | 40%* |
| Emergency Room | Deductible + 20% | Deductible + 20% |
| Telemedicine | 20%* | — |
| X-Ray/Lab | 20%* | 40%* |
| Outpatient/Inpatient** | 20%* | 40%* |
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
- —
X-Ray/Lab
- In-Network
- 20%*
- Out-of-Network
- 40%*
Outpatient/Inpatient**
- In-Network
- 20%*
- Out-of-Network
- 40%*
- ** Blue Distinction Center Providers = 10% Coinsurance after deductible
- * After deductible
Retail Rx (30-Day Supply)
| Tier | Preventive In-Network | Preventive Out-of-Network | Non-Preventive In-Network | Non-Preventive Out-of-Network |
|---|---|---|---|---|
| Generic | $10 | 40%* | 20%* | 40%* |
| Preferred brand | $50 | 40%* | 20%* | 40%* |
| Non preferred brand | $100 | 40%* | 20%* | 40%* |
| Specialty | $150 | 40%* | 20%* | 40%* |
Generic
- Preventive In-Network
- $10
- Preventive Out-of-Network
- 40%*
- Non-Preventive In-Network
- 20%*
- Non-Preventive Out-of-Network
- 40%*
Preferred brand
- Preventive In-Network
- $50
- Preventive Out-of-Network
- 40%*
- Non-Preventive In-Network
- 20%*
- Non-Preventive Out-of-Network
- 40%*
Non preferred brand
- Preventive In-Network
- $100
- Preventive Out-of-Network
- 40%*
- Non-Preventive In-Network
- 20%*
- Non-Preventive Out-of-Network
- 40%*
Specialty
- Preventive In-Network
- $150
- Preventive Out-of-Network
- 40%*
- Non-Preventive In-Network
- 20%*
- Non-Preventive Out-of-Network
- 40%*
- * After deductible
Mail Order Rx (90-Day Supply)
| Tier | Preventive In-Network | Preventive Out-of-Network | Non-Preventive In-Network | Non-Preventive Out-of-Network |
|---|---|---|---|---|
| Generic | $20 | 40%* | 20%* | 40%* |
| Preferred brand | $100 | 40%* | 20%* | 40%* |
| Non preferred brand | $200 | 40%* | 20%* | 40%* |
| Specialty | $300 | 40%* | 20%* | 40%* |
Generic
- Preventive In-Network
- $20
- Preventive Out-of-Network
- 40%*
- Non-Preventive In-Network
- 20%*
- Non-Preventive Out-of-Network
- 40%*
Preferred brand
- Preventive In-Network
- $100
- Preventive Out-of-Network
- 40%*
- Non-Preventive In-Network
- 20%*
- Non-Preventive Out-of-Network
- 40%*
Non preferred brand
- Preventive In-Network
- $200
- Preventive Out-of-Network
- 40%*
- Non-Preventive In-Network
- 20%*
- Non-Preventive Out-of-Network
- 40%*
Specialty
- Preventive In-Network
- $300
- Preventive Out-of-Network
- 40%*
- Non-Preventive In-Network
- 20%*
- Non-Preventive Out-of-Network
- 40%*
- * After deductible
Plan Notes
- Tobacco user surcharge: $600 per year. Avoid it by: Complete the tobacco affidavit in Workday during the annual benefits open enrollment period, or complete the Tobacco Cessation program offered through BCBS.
- Prescription drug coverage is coordinated with your medical plan and administered through BCBSTX.
- Affordable Care Act (ACA) preventive drugs are covered at 100%.