BCBSTX Medical and Prescription Drugs
We offer three medical plans through Blue Cross Blue Shield of Texas (BCBSTX). All plans include prescription drug coverage, and they cover essential preventive care at no cost to you when you visit in-network providers.
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits.
Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Premium PPO
Benefit Highlights
In-Network
Deductible (Individual/Family)
$600/$1,800
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$50 copay
Urgent Care
Next Level PRIME locations: $0 copay
All Others: $60 copay
Emergency Room
$350 copay/visit plus 20% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$80 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0 copay
Preferred Brand
$125 copay
Non-Preferred Brand
$200 copay
Out-of-Network
Deductible (Individual/Family)
$1,800/$5,400
Out-of-Pocket Max (Individual/Family)
$10,000/$20,000
Preventive Care
$0
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$350 copay/visit plus 20% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Bi-Weekly Plan (Non-Nicotine User)
Employee Only: $140.75
Employee and Spouse: $607.89
Employee and Child(ren): $349.20
Employee and Family: $786.27
Bi-Weekly Plan (Nicotine User)
Employee Only: $197.25
Employee and Spouse: $664.39
Employee and Child(ren): $405.70
Employee and Family: $842.77
Core EPO
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$1,200/$3,600
Out-of-Pocket Max (Individual/Family)
$6,350 / $12,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
$35 copay
Specialist Visit
$60 copay
Urgent Care
Next Level PRIME locations: $0 copay
All Others: $60 copay
Emergency Room
$400 copay/visit plus 30% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$0 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$80 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic:
$0 copay
Preferred Brand
$125 copay
Non-Preferred Brand
$200 copay
Bi-Weekly Plan Cost (Non-Nicotine User)
Employee Only: $49.61
Employee and Spouse: $354.12
Employee and Child(ren): $203.40
Employee and Family: $415.23
Bi-Weekly Plan Cost (Nicotine User)
Employee Only: $106.11
Employee and Spouse: $410.62
Employee and Child(ren): $259.90
Employee and Family: $471.73
Blue Essentials HMO (Includes Kelsey-Seybold)
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$750/$2,250
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$45 copay
Urgent Care
Next Level PRIME locations: $0 copay
All Others: $60 copay
Emergency Room
$350 copay/visit plus 20% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$0 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$80 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0 copay
Preferred Brand
$125 copay
Non-Preferred Brand
$200 copay
Bi-Weekly Plan Cost (Non-Nicotine User)
Employee Only: $38.17
Employee and Spouse: $316.77
Employee and Child(ren): $181.86
Employee and Family: $369.00
Bi-Weekly Plan Cost (Nicotine User)
Employee Only: $94.67
Employee and Spouse: $373.27
Employee and Child(ren): $238.36
Employee and Family: $425.50