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HMO
Copay-based, in-network-only plan with no out-of-network coverage.
Plan details
Availability
All eligible employees
HSA Eligible
No
FSA Eligible
Yes
Premium contributions
HMO : Full-Time
| Coverage Tier | Premium | Non-Tobacco | Tobacco |
|---|---|---|---|
| Employee Only | Bi-weekly | $74.64 | $97.72 |
| Weekly | $37.32 | $48.86 | |
| Employee + Spouse | Bi-weekly | $164.21 | $187.28 |
| Weekly | $82.10 | $93.64 | |
| Employee + Child(ren) | Bi-weekly | $138.07 | $161.15 |
| Weekly | $69.03 | $80.57 | |
| Employee + Family | Bi-weekly | $238.84 | $261.92 |
| Weekly | $119.42 | $130.96 |
HMO : Part-Time
| Coverage Tier | Premium | Non-Tobacco | Tobacco |
|---|---|---|---|
| Employee Only | Bi-weekly | $74.64 | $97.72 |
| Weekly | $37.32 | $48.86 | |
| Employee + Spouse | Bi-weekly | $312.74 | $335.82 |
| Weekly | $156.37 | $167.91 | |
| Employee + Child(ren) | Bi-weekly | $262.98 | $286.06 |
| Weekly | $131.49 | $143.03 | |
| Employee + Family | Bi-weekly | $454.90 | $477.98 |
| Weekly | $227.45 | $238.99 |
Deductible and Out-of-Pocket
| Detail | In-Network |
|---|---|
| Deductible (Individual) | $1,000 |
| Deductible (Family) | $2,000 |
| Coinsurance (plan pays) | 100% after deductible |
| Out-of-Pocket Max (Individual) | $3,500 |
| Out-of-Pocket Max (Family) | $7,000 |
What you pay per visit
| Service | In-Network |
|---|---|
| Preventive Care | 100% |
| Primary Care Visit | $10 copay |
| Specialist Visit | $30 copay |
| Diagnostic Care | 100% after deductible |
| Urgent Care | $50 copay |
| Emergency Room | $500 copay after deductible |
Pharmacy benefits
| Tier | Retail (30 day) | Mail Order (90 day) |
|---|---|---|
| Generic | $10 copay | $25 copay |
| Preferred | $30 copay | $75 copay |
| Non Preferred | $50 copay | $150 copay |
Plan Notes
- HMO plan has no out-of-network coverage.
HMO plan contacts
BCBS of TX
BCBS of TX (Prime Therapeutics) — Pharmacy