Blue Cross Blue Shield of Texas (BCBSTX)
PPO
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.
PPO
Plan Details
Carrier
Blue Cross Blue Shield of Texas (BCBSTX)
Plan Type
PPO
Out-of-Network Coverage
Yes
HSA Eligible
No
FSA Eligible
Yes — Healthcare FSA
Premiums - Biweekly Contributions
| Coverage Tier | Biweekly Contribution |
|---|---|
| Employee Only | $94.07 |
| Employee + Spouse | $174.80 |
| Employee + Child(ren) | $147.89 |
| Employee + Family | $248.65 |
Employee Only
- Biweekly Contribution
- $94.07
Employee + Spouse
- Biweekly Contribution
- $174.80
Employee + Child(ren)
- Biweekly Contribution
- $147.89
Employee + Family
- Biweekly Contribution
- $248.65
Deductible - Out of Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Annual Deductible - Individual | $1,500 | $3,000 |
| Annual Deductible - Family | $3,000 | $6,000 |
| Coinsurance (You Pay) | 20%* | 40%* |
| Annual Out-of-Pocket Maximum - Individual | $6,000 | $12,000 |
| Annual Out-of-Pocket Maximum - Family | $8,000 | $16,000 |
Annual Deductible - Individual
- In-Network
- $1,500
- Out-of-Network
- $3,000
Annual Deductible - Family
- In-Network
- $3,000
- Out-of-Network
- $6,000
Coinsurance (You Pay)
- In-Network
- 20%*
- Out-of-Network
- 40%*
Annual Out-of-Pocket Maximum - Individual
- In-Network
- $6,000
- Out-of-Network
- $12,000
Annual Out-of-Pocket Maximum - Family
- In-Network
- $8,000
- Out-of-Network
- $16,000
- * After deductible
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | 100% No Deductible | 100% No Deductible |
| Physician Office | $30 | 40%* |
| Specialist Office | $60 | 40%* |
| Urgent Care | $80 | 40%* |
| Emergency Room | Deductible + 20% | Deductible + 20% |
| Telemedicine | $0 | — |
| 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
- $30
- Out-of-Network
- 40%*
Specialist Office
- In-Network
- $60
- Out-of-Network
- 40%*
Urgent Care
- In-Network
- $80
- Out-of-Network
- 40%*
Emergency Room
- In-Network
- Deductible + 20%
- Out-of-Network
- Deductible + 20%
Telemedicine
- In-Network
- $0
- 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 | Copay + 40% | $10 | Copay + 40% |
| Preferred brand | $50 | Copay + 40% | $50 | Copay + 40% |
| Non preferred brand | $100 | Copay + 40% | $100 | Copay + 40% |
| Specialty | $150 | Copay + 40% | $150 | Copay + 40% |
Generic
- Preventive In-Network
- $10
- Preventive Out-of-Network
- Copay + 40%
- Non-Preventive In-Network
- $10
- Non-Preventive Out-of-Network
- Copay + 40%
Preferred brand
- Preventive In-Network
- $50
- Preventive Out-of-Network
- Copay + 40%
- Non-Preventive In-Network
- $50
- Non-Preventive Out-of-Network
- Copay + 40%
Non preferred brand
- Preventive In-Network
- $100
- Preventive Out-of-Network
- Copay + 40%
- Non-Preventive In-Network
- $100
- Non-Preventive Out-of-Network
- Copay + 40%
Specialty
- Preventive In-Network
- $150
- Preventive Out-of-Network
- Copay + 40%
- Non-Preventive In-Network
- $150
- Non-Preventive Out-of-Network
- Copay + 40%
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 | Copay + 40% | $20 | Copay + 40% |
| Preferred brand | $100 | Copay + 40% | $100 | Copay + 40% |
| Non preferred brand | $200 | Copay + 40% | $200 | Copay + 40% |
| Specialty | $300 | Copay + 40% | $300 | Copay + 40% |
Generic
- Preventive In-Network
- $20
- Preventive Out-of-Network
- Copay + 40%
- Non-Preventive In-Network
- $20
- Non-Preventive Out-of-Network
- Copay + 40%
Preferred brand
- Preventive In-Network
- $100
- Preventive Out-of-Network
- Copay + 40%
- Non-Preventive In-Network
- $100
- Non-Preventive Out-of-Network
- Copay + 40%
Non preferred brand
- Preventive In-Network
- $200
- Preventive Out-of-Network
- Copay + 40%
- Non-Preventive In-Network
- $200
- Non-Preventive Out-of-Network
- Copay + 40%
Specialty
- Preventive In-Network
- $300
- Preventive Out-of-Network
- Copay + 40%
- Non-Preventive In-Network
- $300
- Non-Preventive Out-of-Network
- Copay + 40%
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%.