HDHP medical plan
HDHP
Medical benefits are provided through Blue Cross Blue Shield of Texas (BCBSTX).
HDHP
Plan Details
- Carrier
- Blue Cross Blue Shield of Texas (BCBSTX)
- Plan Type
- HDHP
- Out-of-Network Coverage
- Yes
- HSA Eligible
- Yes
- FSA Eligible
- Limited Purpose FSA only
| Coverage Tier | Biweekly Contribution |
|---|---|
| Employee only | $79.05 |
| Employee + spouse | $142.97 |
| Employee + child(ren) | $120.88 |
| Employee + family | $199.15 |
Employee only
- Biweekly Contribution
- $79.05
Employee + spouse
- Biweekly Contribution
- $142.97
Employee + child(ren)
- Biweekly Contribution
- $120.88
Employee + family
- Biweekly Contribution
- $199.15
| Feature | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Annual deductible - Individual | $3,500 | $5,600 |
| Annual deductible - Family | $7,000 | $11,200 |
| Coinsurance (you pay) | 20%* | 40%* |
| Annual out-of-pocket maximum (maximum includes deductible) - Individual | $5,000 | $10,000 |
| Annual out-of-pocket maximum (maximum includes deductible) - Family | $7,000 | $14,000 |
Annual deductible - Individual
- IN-NETWORK
- $3,500
- OUT-OF-NETWORK
- $5,600
Annual deductible - Family
- IN-NETWORK
- $7,000
- OUT-OF-NETWORK
- $11,200
Coinsurance (you pay)
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Annual out-of-pocket maximum (maximum includes deductible) - Individual
- IN-NETWORK
- $5,000
- OUT-OF-NETWORK
- $10,000
Annual out-of-pocket maximum (maximum includes deductible) - Family
- IN-NETWORK
- $7,000
- OUT-OF-NETWORK
- $14,000
*After deductible
| Service | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive care | 100% No Deductible | 100% No Deductible |
| Physician office | 20%* | 40%* |
| Specialist office | 20%* | 40%* |
| Urgent care | 20%* | 40%* |
| Emergency room | Deductible + 20% | Deductible + 20% |
| Telemedicine | 20%* | N/A |
| 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
- 20%*
- OUT-OF-NETWORK
- 40%*
Specialist office
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Urgent care
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Emergency room
- IN-NETWORK
- Deductible + 20%
- OUT-OF-NETWORK
- Deductible + 20%
Telemedicine
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- N/A
X-ray/lab
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Outpatient/inpatient**
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
*After deductible
** Blue Distinction Center Providers = 10% Coinsurance after deductible
| Drug Tier | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive drugs - Generic | $10 | 40%* |
| Preventive drugs - Preferred brand | $50 | 40%* |
| Preventive drugs - Non-preferred brand | $100 | 40%* |
| Preventive drugs - Specialty | $150 | 40%* |
| Non-preventive drugs - Generic | 20%* | 40%* |
| Non-preventive drugs - Preferred brand | 20%* | 40%* |
| Non-preventive drugs - Non-preferred brand | 20%* | 40%* |
| Non-preventive drugs - Specialty | 20%* | 40%* |
Preventive drugs - Generic
- IN-NETWORK
- $10
- OUT-OF-NETWORK
- 40%*
Preventive drugs - Preferred brand
- IN-NETWORK
- $50
- OUT-OF-NETWORK
- 40%*
Preventive drugs - Non-preferred brand
- IN-NETWORK
- $100
- OUT-OF-NETWORK
- 40%*
Preventive drugs - Specialty
- IN-NETWORK
- $150
- OUT-OF-NETWORK
- 40%*
Non-preventive drugs - Generic
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Non-preventive drugs - Preferred brand
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Non-preventive drugs - Non-preferred brand
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Non-preventive drugs - Specialty
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
*After deductible
| Drug Tier | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive drugs - Generic | $20 | 40%* |
| Preventive drugs - Preferred brand | $100 | 40%* |
| Preventive drugs - Non-preferred brand | $200 | 40%* |
| Preventive drugs - Specialty | $300 | 40%* |
| Non-preventive drugs - Generic | 20%* | 40%* |
| Non-preventive drugs - Preferred brand | 20%* | 40%* |
| Non-preventive drugs - Non-preferred brand | 20%* | 40%* |
| Non-preventive drugs - Specialty | 20%* | 40%* |
Preventive drugs - Generic
- IN-NETWORK
- $20
- OUT-OF-NETWORK
- 40%*
Preventive drugs - Preferred brand
- IN-NETWORK
- $100
- OUT-OF-NETWORK
- 40%*
Preventive drugs - Non-preferred brand
- IN-NETWORK
- $200
- OUT-OF-NETWORK
- 40%*
Preventive drugs - Specialty
- IN-NETWORK
- $300
- OUT-OF-NETWORK
- 40%*
Non-preventive drugs - Generic
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Non-preventive drugs - Preferred brand
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Non-preventive drugs - Non-preferred brand
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
Non-preventive drugs - Specialty
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
*After deductible
Plan Notes
- You’ll pay less in premiums. (Think less money from your paycheck.)
- You’ll pay for the full cost of non-preventive medical services until you reach your deductible.
- You may also use your Health Savings Account (HSA) to pay for Healthcare expenses.
- If you expect to mostly use preventive care (which is covered), this plan could be for you.
- You must call BCBS Health Advocacy Solutions to receive approval for MRI and CT Scan imaging, or you will receive a $100 penalty fee.