Blue Advantage Bronze HMO℠ 301

33602TX0460807
Bronze
HMO

Blue Advantage Bronze HMO℠ 301 is a Bronze HMO plan by Blue Cross and Blue Shield of Texas.

Locations

Blue Advantage Bronze HMO℠ 301 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Blue Advantage Bronze HMO℠ 301 33602TX0460807.
Insurer: Blue Cross and Blue Shield of Texas
Network Type: HMO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 33602TX0460807

Cost-Sharing Overview

Blue Advantage Bronze HMO℠ 301 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Advantage Bronze HMO℠ 301?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Blue Advantage Bronze HMO℠ 301 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: Referrals are required for some services. Please check with your Medical Group for details.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue Advantage Bronze HMO℠ 301 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: No coverage for any services, supplies or drugs received by a Member outside of the United States, except for Emergency Care
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Coverage outside our service area is available for Emergency and Urgent Care services only.
National Network: No

Additional Benefits and Cost-Sharing

Blue Advantage Bronze HMO℠ 301 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
N/A / No Charge after deductible /
Specialist Visit
Covered
N/A / No Charge after deductible /
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
N/A / No Charge after deductible /
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
N/A / No Charge after deductible / Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Outpatient Surgery Physician/Surgical Services
Covered
N/A / No Charge after deductible /
Hospice Services
Covered
N/A / No Charge after deductible /
Routine Dental Services (Adult)
Not Covered
/ /
Infertility Treatment
Not Covered
/ /
Long-Term/Custodial Nursing Home Care
Not Covered
/ /
Private-Duty Nursing
Not Covered
/ /
Routine Eye Exam (Adult)
Not Covered
/ /
Urgent Care Centers or Facilities
Covered
N/A / No Charge after deductible /
Home Health Care Services
Covered
N/A / No Charge after deductible / 60 Visit(s) per Benefit Period
Emergency Room Services
Covered
N/A / No Charge after deductible /
Emergency Transportation/Ambulance
Covered
N/A / No Charge after deductible / Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
N/A / No Charge after deductible / In the case of an elective inpatient Hospital Admission, the call for Preauthorization should be made at least two working days before You are admitted unless it would delay Emergency Care. In an emergency, Preauthorization should take place within two working days after admission, or as soon thereafter as reasonably possible. A benefits management nurse will follow up with Your Provider?s office. See benefit book for details.
Inpatient Physician and Surgical Services
Covered
N/A / No Charge after deductible /
Bariatric Surgery
Not Covered
/ /
Cosmetic Surgery
Not Covered
/ / Covered only for the correction of congenital deformities in children, conditions resulting from accidental injuries, and reconstructive surgery following cancer surgery including prosthesis in the event of a mastectomy.
Skilled Nursing Facility
Covered
N/A / No Charge after deductible / 25 Days per Benefit Period
Prenatal and Postnatal Care
Covered
N/A / No Charge after deductible / First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.
Delivery and All Inpatient Services for Maternity Care
Covered
N/A / No Charge after deductible /
Mental/Behavioral Health Outpatient Services
Covered
N/A / No Charge after deductible /
Mental/Behavioral Health Inpatient Services
Covered
N/A / No Charge after deductible / In order to receive maximum benefits, all inpatient treatment for Chemical Dependency, Serious Mental Illness and Mental Health Care must be preauthorized unless it would delay Emergency Care. In an emergency, Preauthorization should take place within two working days after admission, or as soon thereafter as reasonably possible. A benefits management nurse will follow up with Your Provider?s office. See benefit book for details.
Substance Abuse Disorder Outpatient Services
Covered
N/A / No Charge after deductible /
Substance Abuse Disorder Inpatient Services
Covered
N/A / No Charge after deductible / In order to receive maximum benefits, all inpatient treatment for Chemical Dependency, Serious Mental Illness and Mental Health Care must be preauthorized unless it would delay Emergency Care. In an emergency, Preauthorization should take place within two working days after admission, or as soon thereafter as reasonably possible. A benefits management nurse will follow up with Your Provider?s office. See benefit book for details.
Generic Drugs
Covered
N/A / No Charge after deductible / Certain generic drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details.
Preferred Brand Drugs
Covered
N/A / No Charge after deductible / Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.
Non-Preferred Brand Drugs
Covered
N/A / No Charge after deductible / Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.
Specialty Drugs
Covered
N/A / No Charge after deductible / Certain specialty drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.
Outpatient Rehabilitation Services
Covered
N/A / No Charge after deductible / 35 Visit(s) per Benefit Period Limit includes muscle manipulations.
Habilitation Services
Covered
N/A / No Charge after deductible / 35 Visit(s) per Benefit Period Limit includes muscle manipulations.
Chiropractic Care
Covered
N/A / No Charge after deductible / 35 Visit(s) per Benefit Period Muscle manipulations included in Rehabilitation and Habilitation limits.
Durable Medical Equipment
Covered
N/A / No Charge after deductible /
Hearing Aids
Covered
N/A / No Charge after deductible / 2 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
N/A / No Charge after deductible / CT scan for heart disease screening. Maximum 1 visit for EDT per every 5 years. Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Preventive Care/Screening/Immunization
Covered
No Charge / N/A /
Routine Foot Care
Not Covered
/ / Foot care in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency.
Acupuncture
Not Covered
/ /
Weight Loss Programs
Not Covered
/ /
Routine Eye Exam for Children
Covered
No Charge / N/A / 1 Visit(s) per Benefit Period When purchasing Out of Network, reimbursements are available. See benefit book for details.
Eye Glasses for Children
Covered
No Charge / N/A / 1 Item(s) per Benefit Period Provider-designated frames are covered. An allowance may apply to non-provider-designated frames. Coinsurance may apply to non-provider-designated frames on the remaining balance over the allowance. See benefit book for details.
Dental Check-Up for Children
Not Covered
/ /
Rehabilitative Speech Therapy
Covered
N/A / No Charge after deductible /
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
N/A / No Charge after deductible / 35 Visit(s) per Benefit Period Limit includes muscle manipulations.
Well Baby Visits and Care
Covered
No Charge / N/A /
Laboratory Outpatient and Professional Services
Covered
N/A / No Charge after deductible / Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
X-rays and Diagnostic Imaging
Covered
N/A / No Charge after deductible / Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Basic Dental Care – Child
Not Covered
/ /
Orthodontia – Child
Not Covered
/ /
Major Dental Care – Child
Not Covered
/ /
Basic Dental Care – Adult
Not Covered
/ /
Orthodontia – Adult
Not Covered
/ /
Major Dental Care – Adult
Not Covered
/ /
Abortion for Which Public Funding is Prohibited
Not Covered
/ /
Transplant
Covered
N/A / No Charge after deductible /
Accidental Dental
Covered
N/A / No Charge after deductible /
Dialysis
Covered
N/A / No Charge after deductible /
Allergy Testing
Covered
N/A / No Charge after deductible /
Chemotherapy
Covered
N/A / No Charge after deductible /
Radiation
Covered
N/A / No Charge after deductible /
Diabetes Education
Covered
N/A / No Charge after deductible /
Prosthetic Devices
Covered
N/A / No Charge after deductible /
Infusion Therapy
Covered
N/A / No Charge after deductible / Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Treatment for Temporomandibular Joint Disorders
Covered
N/A / No Charge after deductible /
Nutritional Counseling
Not Covered
/ / Covered for Preventive and Diabetes services only.
Reconstructive Surgery
Covered
N/A / No Charge after deductible /
Prescription Drugs Other
Covered
N/A / No Charge after deductible / Clinical Programs such as, Prior Authorization, Step Therapy and Quantity/dispensing limits may apply. See benefit book for details.

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue Advantage Bronze HMO℠ 301 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Blue Advantage Bronze HMO℠ 301 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Blue Advantage Bronze HMO℠ 301?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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