MyBlue Health Silver℠ 405

33602TX0461130
Silver
HMO

MyBlue Health Silver℠ 405 is a Silver HMO plan by Blue Cross and Blue Shield of Texas.

IMPORTANT: You are viewing the 2024 version of MyBlue Health Silver℠ 405 33602TX0461130. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

MyBlue Health Silver℠ 405 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of MyBlue Health Silver℠ 405 33602TX0461130.
Insurer: Blue Cross and Blue Shield of Texas
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 33602TX0461130

Cost-Sharing Overview

MyBlue Health Silver℠ 405 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 MyBlue Health Silver℠ 405?

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

MyBlue Health Silver℠ 405 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 MyBlue Health Silver℠ 405 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

MyBlue Health Silver℠ 405 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
$0.00 Not ApplicableNot Applicable 100.00% To obtain No Charge for selected services from Sanitas Provider, you must select a Sanitas Provider as your Primary Care Physician. For all other in network providers, office visits will be subject to a copay.
Specialist Visit
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$600.00 Copay with deductible 30.00% Coinsurance after deductibleNot Applicable 100.00% Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. Member will be responsible for copay per outpatient surgery admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Outpatient Surgery Physician/Surgical Services
Covered
$100.00 Copay with deductible 40.00% Coinsurance after deductibleNot Applicable 100.00% Member will be responsible for copay per outpatient surgery service before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Hospice Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Not covered unless medically necessary.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 Not ApplicableNot Applicable 100.00% Under this plan, the first two urgent care visits are covered at no charge. The listed copay will be applied for all subsequent urgent care visits. See benefit book for details.
Home Health Care Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Benefit Period
Emergency Room Services
Covered
$950.00 Copay with deductible 40.00% Coinsurance after deductible$950.00 Copay with deductible 40.00% Coinsurance after deductible Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Emergency Transportation/Ambulance
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance 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
$850.00 Copay per Stay with deductible 40.00% Coinsurance after deductibleNot Applicable 100.00% Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Inpatient Physician and Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%25.0 Days per Benefit Period
Prenatal and Postnatal Care
Covered
$30.00 Not ApplicableNot Applicable 100.00% 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
$850.00 Copay with deductible 40.00% Coinsurance after deductibleNot Applicable 100.00% Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
$850.00 Copay per Stay with deductible 40.00% Coinsurance after deductibleNot Applicable 100.00% Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
$850.00 Copay per Stay with deductible 40.00% Coinsurance after deductibleNot Applicable 100.00% Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.
Generic Drugs
Covered
$5.00 Not ApplicableNot Applicable 100.00% Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. 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
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. 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
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00% Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. 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
Not Applicable 45.00% Coinsurance after deductibleNot Applicable 100.00% Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details. 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Benefit Period Limit includes muscle manipulations.
Habilitation Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Benefit Period Limit includes muscle manipulations.
Chiropractic Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Benefit Period Muscle manipulations included in Rehabilitation and Habilitation limits.
Durable Medical Equipment
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years Coverage is limited to 1 hearing aid per ear every 36 month
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% 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 Not ApplicableNot Applicable 100.00%
Routine Foot Care
Not Covered
Covered when medically necessary
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 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 No ChargeNot Applicable 100.00%1.0 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Benefit Period Limit includes muscle manipulations.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% 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
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
$100.00 Not ApplicableNot Applicable 100.00% 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Excludes any non-surgical (dental restorations, orthodontics, or physical therapy) or non-diagnostic services or supplies (oral appliances, oral splints, oral orthotics, devices, or prosthetics) provided for the treatment of the temporomandibular joint and all adjacent or related muscles and nerves.
Nutritional Counseling
Not Covered
Covered for Preventive and Diabetes services only.
Reconstructive Surgery
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following MyBlue Health Silver℠ 405 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 MyBlue Health Silver℠ 405 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 MyBlue Health Silver℠ 405?

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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