Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.
Benefit Explanation: When prescription drugs are bought from an out of network pharmacy additional charges may apply. 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
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.
Benefit Explanation: When prescription drugs are bought from an out of network pharmacy additional charges may apply. 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: $5.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.
Benefit Explanation: Certain generic drugs may have a higher cost share amount than is listed on this page. When prescription drugs are bought from an out of network pharmacy additional charges may apply. See benefit book for details.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 45.00% Coinsurance after deductible
Covered: Covered
Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.
Benefit Explanation: Certain specialty drugs may have a higher cost share amount than is listed on this page. If prescription drugs are bought from an out of network pharmacy additional charges may apply. 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: $850.00 Copay per Stay with deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: In the case of an elective inpatient Hospital Admission, the call for Preauthorization should be made at least two working days before You are admitted unless it would delay Emergency Care. In an emergency, Preauthorization should take place within two working days after admission, or as soon thereafter as reasonably possible. A benefits management nurse will follow up with Your Provider’s office. See benefit book for details.
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: 50.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $950.00 Copay with deductible
CoInsurance: 50.00% 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: $60.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: $850.00 Copay with deductible
CoInsurance: 50.00% 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.
Pre and Postnatal Office Visit
CoPay: $75.00
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
Covered: Not Covered
Routine Dental Checkups for Adults
Covered: Not Covered
Basic Dental Care - Adult
Covered: Not Covered
Basic Dental Care - Child
Covered: Not Covered
Major Dental Care - Adult
Covered: Not Covered
Major Dental Care - Child
Covered: Not Covered
HealthMarkets Insurance Agency d/b/a Insphere Insurance Solutions, Inc is an independent, authorized agent for Blue Cross and Blue Shield of Texas.
Blue Cross and Blue Shield of Texas: A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
Effective dates are available on the first of the month only, unless otherwise required by law. Applications must be received by Blue Cross and Blue Shield of Texas within the defined enrollment period to be accepted.
1-817-813-4562, TTY 711
