Medical
Medical coverage offers healthcare protection for you and your family. 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.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The difference between the plans is what you pay out of pocket when you receive care, network (PPO/HMO), and cost per paycheck. To learn more about our BCBSTX offerings, you can visit our BCBSTX TXOA microsite at bcbstx.com/txoa.
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 calendar 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 Prime PPO
Plan Information
Plan Name: BCBSTX Prime PPO
Policy Number: 324679
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)
$2,500/$5,000
Preventive Care
$0
Primary Care Visit
$25 Copay
Specialist Visit
$50 Copay
Urgent Care
$75 Copay
Emergency Room
$150 plus deductible and 10% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay
Preferred Brand
$40 Copay
Non-Preferred Brand
$75 Copay
Specialty
$100 Copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$25 Copay
Preferred Brand
$100 Copay
Non-Preferred Brand
$187.50 Copay
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
50% after deductible
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$150 plus deductible and 10% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay, then 50%
Preferred Brand
$40 Copay, then 50%
Non-Preferred Brand
$75 Copay, then 50%
Specialty
$100 Copay, then 50%
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
BCBSTX Select Choice PPO
Plan Information
Plan Name: BCBSTX Select Choice PPO
Policy Number: 324679
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)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
$25 Copay
Specialist Visit
$50 Copay
Urgent Care
$75 Copay
Emergency Room
$250 Copay, then 20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay
Preferred Brand
$40 Copay
Non-Preferred Brand
$80 Copay
Specialty
$150 Copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$25 Copay
Preferred Brand
$100 Copay
Non-Preferred Brand
$200 Copay
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$6,000/$12,000
Out-of-Pocket Max (Individual/Family)
$12,000/$24,000
Preventive Care
50% after deductible
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$250 Copay, then 20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay plus 50% coinsurance
Preferred Brand
$40 Copay plus 50% coinsurance
Non-Preferred Brand
$80 Copay plus 50% coinsurance
Specialty
$150 Copay plus 50% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
BCBSTX Choice PPO
Plan Information
Plan Name: BCBSTX Choice PPO
Policy Number: 324679
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)
$4,000/$8,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
$0
Primary Care Visit
$35 Copay
Specialist Visit
$75 Copay
Urgent Care
$75 Copay
Emergency Room
$250 Copay, then 20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay
Preferred Brand
$50 Copay
Non-Preferred Brand
$90 Copay
Specialty
$90 Copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$25 Copay
Preferred Brand
$125 Copay
Non-Preferred Brand
$225 Copay
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$12,000/$24,000
Out-of-Pocket Max (Individual/Family)
$12,000/$24,000
Preventive Care
50% after deductible
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$250 Copay, then 20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay, then 50%
Preferred Brand
$50 Copay, then 50%
Non-Preferred Brand
$90 Copay, then 50%
Specialty
$90 Copay, then 50%
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
BCBSTX HSA
Plan Information
Plan Name: BCBSTX HSA
Policy Number: 324679
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)
$3,300/$6,600
Out-of-Pocket Max (Individual/Family)
$3,300/$6,600
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
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
$0 after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
Not Covered
Out-of-Network
Deductible (Individual/Family)
$6,000/$12,000
Out-of-Pocket Max (Individual/Family)
$10,000/$20,000
Preventive Care
50% after deductible
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
$0 after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Contact Information
BCBSTX Value HSA
Plan Information
Plan Name: BCBSTX Value HSA
Policy Number: 324679
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)
$7,000/$14,000
Out-of-Pocket Max (Individual/Family)
$7,000/$14,000
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
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$14,000/$28,000
Out-of-Pocket Max (Individual/Family)
$28,000/$56,000
Preventive Care
50% after deductible
Primary Care Visit
50% after deductible
Specialist Visit
50% after deductible
Urgent Care
50% after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
BCBSTX Prime HMO
Plan Information
Plan Name: BCBSTX Prime HMO
Policy Number: 324679
Effective Date: 01/01/2025
Provider Network: BlueCross BlueShield of Texas
You are required to nominate a PCP and must obtain referrals to specialists.
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 Only
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Preventive Care
$0
Primary Care Visit
$25 Copay
Specialist Visit
$50 Copay
Urgent Care
$75 Copay
Emergency Room
$150 then 10% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay
Preferred Brand
$40 Copay
Non-Preferred Brand
$75 Copay
Specialty
$100 Copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$25 Copay
Preferred Brand
$100 Copay
Non-Preferred Brand
$187.50 Copay
Specialty
Not covered
Contact Information
BCBSTX Choice HMO
Plan Information
Plan Name: BCBSTX Choice HMO
Policy Number: 324679
Effective Date: 01/01/2025
Provider Network: BlueCross BlueShield of Texas
You are required to nominate a PCP and must obtain referrals to specialists.
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 Only
Deductible (Individual/Family)
$4,000/$8,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
$0
Primary Care Visit
$35 Copay
Specialist Visit
$75 Copay
Urgent Care
$75 Copay
Emergency Room
$250 plus 20% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay
Preferred Brand
$50 Copay
Non-Preferred Brand
$90 Copay
Specialty
$90 Copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$25 Copay
Preferred Brand
$125 Copay
Non-Preferred Brand
$225 Copay
Specialty
Not Covered
Plan Documents
Contact Information
BCBSTX Value HMO
Plan Information
Plan Name: BCBSTX Value HMO
Policy Number: 324679
Effective Date: 01/01/2025
Provider Network: BlueCross BlueShield of Texas
You are required to nominate a PCP and must obtain referrals to specialists.
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)
$6,000/$12,000
Out-of-Pocket Max (Individual/Family)
$7,900/$15,800
Preventive Care
$0
Primary Care Visit
$35 Copay
Specialist Visit
$70 Copay
Urgent Care
$75 Copay
Emergency Room
$500 plus 30% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 Copay
Preferred Brand
$50 Copay
Non-Preferred Brand
$100 Copay
Specialty
$250 Copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$25 Copay
Preferred Brand
$125 Copay
Non-Preferred Brand
$250 Copay
Specialty
Not covered