Blue Advantage Plus Silver℠ 202

Blue Cross and Blue Shield of Texas

Silver

Ind. deductible: $1,250
Family deductible: $1,250
Ind. OOP max: $10,500
Family OOP max: $10,500

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 87% AV Level Silver Plan 94% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$786	—
30	$892	—
40	$1,005	—
50	$1,404	—
60	$2,134	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	No charge

Specialist

Benefit	In-network
Specialist Visit	50.00% Coinsurance after deductible

Hospital

Benefit	In-network
Emergency Room Services	$1000.00 Copay with deductible
Inpatient Hospital Services (e.g., Hospital Stay)	$950.00 Copay per Stay with deductible
Outpatient Surgery Physician/Surgical Services	$50.00 Copay with deductible
Urgent Care Centers or Facilities	$0.00

Pharmacy

Benefit	In-network
Generic Drugs	$5.00
Non-Preferred Brand Drugs	$0.00
Preferred Brand Drugs	$0.00
Specialty Drugs	45.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	$950.00 Copay per Stay with deductible
Mental/Behavioral Health Outpatient Services	$0.00

Other

Benefit	In-network
Bariatric Surgery	Not covered
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Routine Dental Services (Adult)	Not covered
Accidental Dental	$0.00
Acupuncture	Not covered
Allergy Testing	30.00%
Abortion for Which Public Funding is Prohibited	Not covered
Chemotherapy	50.00% Coinsurance after deductible
Chiropractic Care	40.00% Coinsurance after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	$300.00
Dental Check-Up for Children	Not covered
Diabetes Education	50.00% Coinsurance after deductible
Dialysis	$0.00
Durable Medical Equipment	30.00%
Emergency Transportation/Ambulance	50.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	$0.00
Hearing Aids	30.00%
Home Health Care Services	40.00% Coinsurance after deductible
Hospice Services	30.00%
Imaging (CT/PET Scans, MRIs)	30.00% Coinsurance after deductible
Infertility Treatment	Not covered
Infusion Therapy	$100.00
Inpatient Physician and Surgical Services	40.00% Coinsurance after deductible
Routine Eye Exam (Adult)	Not covered
Laboratory Outpatient and Professional Services	30.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	Not covered
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	30.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$600.00 Copay with deductible
Outpatient Rehabilitation Services	40.00% Coinsurance after deductible
Prenatal and Postnatal Care	$20.00
Private-Duty Nursing	Not covered
Prosthetic Devices	30.00%
Radiation	50.00% Coinsurance after deductible
Reconstructive Surgery	50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	$0.00
Rehabilitative Speech Therapy	$0.00
Routine Eye Exam for Children	No charge
Routine Foot Care	Not covered
Skilled Nursing Facility	30.00%
Substance Abuse Disorder Inpatient Services	$300.00 Copay per Stay with deductible
Substance Abuse Disorder Outpatient Services	40.00% Coinsurance after deductible
Transplant	50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	50.00% Coinsurance after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	30.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 7 geographic areas.