MyBlue Health Silver℠ 405
Blue Cross and Blue Shield of Texas
Plan overview
Medical deductible
Individual: $1500
Family: $3000
Per Person: $1500
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $10600
Family: $21200
Per Person: $10600
Office visit
Primary Doctor
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: To obtain No Charge for selected services, you must choose a PCP from one of the Select Primary Care Physicians Groups. For all other in network providers, office visits will be subject to a copay.
Specialist
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.
Generic drugs
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Certain generic drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details.
Specialty drugs
CoPay: Not Applicable
CoInsurance: 45.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Certain specialty drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.
Inpatient coverage
Hospital services
CoPay: $950.00 Copay per Stay with deductible
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Inpatient services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $1000.00 Copay with deductible
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Urgent care facility
CoPay: $45.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Under this plan, the first two urgent care visits are covered at no charge. The listed copay will be applied for all subsequent urgent care visits. See benefit book for details.
Maternity
Labor and delivery hospital stay
CoPay: $950.00 Copay with deductible
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable.\nMember will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Pre and Postnatal office visit
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit: Visit(s) per Benefit Period
Benefit Explanation: When purchasing Out of Network, reimbursements are available. See benefit book for details.
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).