Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need 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.
BCBSTX CDHP Gold
Plan Information
Plan Name: BCBSTX CDHP Gold
Policy Number: 118708
Effective Date: 01/01/2025
Provider Network: BlueCross BlueShield of Texas
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,600/$3,200
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Preventive Care
$0
Primary Care Visit
10% after deductible
Specialist Visit
10% after deductible
Urgent Care
10% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 31-Day Supply)
Generic
10% after deductible
Generic Maintenance
10% after deductible
Preferred Brand
10% after deductible
Non-Preferred Brand
10% after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
10% after deductible
Generic Maintenance
10% after deductible
Preferred Brand
10% after deductible
Non-Preferred Brand
10% after deductible
Out-of-Network
Deductible (Individual/Family)
$3,000/$6,000
Out-of-Pocket Max (Individual/Family)
$10,000/$20,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 31-Day Supply)
Generic
Not covered
Generic Maintenance
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Generic Maintenance
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
BCBSTX CDHP Silver
Plan Information
Plan Name: BCBSTX CDHP Silver
Policy Number: 118708
Effective Date: 01/01/2025
Provider Network: BlueCross BlueShield of Texas
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$5,750/$11,500
Out-of-Pocket Max (Individual/Family)
$5,750/$11,500
Preventive Care
$0
Primary Care Visit
$0 after deductible
Specialist Visit
$0 after deductible
Urgent Care
$0 after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$0 after deductible
Generic Maintenance
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0 after deductible
Generic Maintenance
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Out-of-Network
Deductible (Individual/Family)
$10,500/$21,000
Out-of-Pocket Max (Individual/Family)
$10,500/$21,000
Preventive Care
$0
Primary Care Visit
$0 after deductible
Specialist Visit
$0 after deductible
Urgent Care
$0 after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Generic Maintenance
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Generic Maintenance
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
BCBSTX PPO
Plan Information
Plan Name: BCBSTX PPO
Policy Number: 118708
Effective Date: 01/01/2025
Provider Network: BlueCross BlueShield of Texas
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$40 copay
Urgent Care
$20 PCP/$40 specialist copay
Emergency Room
$200 copay (In the event of true emergencies only)
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay
Generic Maintenance
$5 copay
Preferred Brand
$25 copay
Non-Preferred Brand
30% (max $100)
Mail-Order Rx (Up to 90-Day Supply)
Generic
2x retail
Generic Maintenance
$0
Preferred Brand
$50 copay
Non-Preferred Brand
30% (max $200)
Out-of-Network
Deductible (Individual/Family)
$1,000/$2,000
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$200 copay (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Generic Maintenance
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Generic Maintenance
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered