Blue Cross and Blue Shield of Texas BlueEdge Individual HSA Plan IV V VI Plan Information
Coverage Level 75%
Physician/Hospital Network BlueChoice or BlueCard Preferred Provider Organization
Lifetime Benefit $5 Million
Individual Out-of-Pocket Expense $3,000
Office Visit Co-pay Deductible and Coinsurance
Family Out-of-Pocket Expense $6,000
Outpatient Physician Medical Services Deductible and Coinsurance
Outpatient Physician Surgical Services Deductible and Coinsurance
Preventative Care 75% after deductible; $300 max per year
Childhood Immunizations 100% to 6 years of age
Inpatient Physician Medical/Surgical Services Deductible and Coinsurance
Outpatient Hospital Services Deductible and Coinsurance
Outpatient Hospital Diagnostic Testing Deductible and Coinsurance
Inpatient Hospital Services and Diagnostic Testing Deductible and Coinsurance
Outpatient Prescription Drugs Deductible and $10 copay/generic; $50 copay/preferred; $65 copay/non-preferred; $5,000 calendar year max
Other Blue Cross and Blue Shield of Texas health insurance plans:
