IN-NETWORK |
OUT-OF-NETWORK |
|
|---|---|---|
| Annual Deductible | $875 single/$1,750 all other coverage levels | $2,625 single/$5,250 all other coverage levels |
| Annual Out-of-Pocket Maximum (includes deductible and office visit copays only) | $3,700 single / $7,400 all other coverage levels | $11,100 single / $22,200 all other coverage levels (excludes amounts above usual and customary) |
| Lifetime Maximum Benefit | Unlimited | Unlimited |
| General Medical Expenses | ||
| Primary Doctor Office Visit | $25 copay | 65% covered after deductible |
| MDLIVE Physician1 | $25 | Not applicable |
| Specialist Office Visit | $40 copay | 65% covered after deductible |
| Inpatient Hospital Care (requires preauthorization) | ||
| Hospitalization2 | 85% covered after deductible | 65% covered after deductible |
| Inpatient Physician and Surgeon Services2 | 85% covered after deductible | 65% covered after deductible |
| Inpatient Lab and X-ray3 | 85% covered after deductible | 65% covered after deductible |
| Outpatient Care | ||
| Outpatient Surgery | 85% covered after deductible; if performed as a part of an office visit and billed by a physician applicable copay applies | 65% covered after deductible |
| Outpatient Laboratory Services & X-ray3 | 85% covered after deductible; if performed as part of an office visit and billed by a physician applicable copay applies | 65% covered after deductible |
| Chiropractic Services | ||
| Spinal Manipulation | $40 copay Maximum of 25 visits each calendar year (in-and out-of-network services combined) |
65% covered after deductible Maximum of 25 visits each calendar year (in-and out-of-network services combined) |
| Preventive Care | ||
| Annual Physical Exam & Immunizations | 100% covered | 65% covered after deductible |
| Well-Baby & Well-Child Exams & Immunizations | 100% covered | 65% covered after deductible |
| Well-Woman Exam | 100% covered | 65% covered after deductible |
| Other Preventive Care & Cancer Screenings4 | 100% covered | 65% covered after deductible |
| Maternity Care5 | ||
| Office Visit: Prenatal/Postnatal | $25 copay, initial visit only | 65% covered after deductible |
| In-Hospital Delivery & Newborn Nursery Services | 85% covered after deductible | 65% covered after deductible |
| Short-Term Rehabilitation Therapy6 | ||
| Outpatient Physical, Speech, Occupational Therapy | 85% covered after deductible; 60-visit combined maximum per year | 65% covered after deductible; 60-visit combined maximum per year |
| Emergency Services | ||
| Hospital Emergency Facility | 85% covered after deductible and after $250 copay | 85% covered after deductible and after $250 copay |
| Non-Emergency Care in a Hospital Emergency Room | Not covered | Not covered |
| Urgent Medical Care (at a non-hospital free standing facility) | 85% covered after $40 copay | 65% covered after deductible |
| Non-Urgent Use of Urgent Care Provider (at a non-hospital free standing facility) | 85% covered after $40 copay | 65% covered after deductible |
| Mental Health, Substance Abuse | ||
| Mental Health/Rehab & Detox Outpatient Coverage | $25 copay | 65% covered after deductible |
| Mental Health/Rehab & Detox Inpatient Coverage | 85% covered after deductible | 65% covered after deductible |
| Residential Treatment Facility (stays in a residential treatment facility for treatment of mental disorders, alcoholism or drug abuse) | 85% covered after deductible | 65% covered after deductible |
| MDLIVE Behavioral Therapy | $25 | Not applicable |
| Other Benefits | ||
| Condition Management | BCBSTX Condition Management programs offer support for people diagnosed with chronic conditions such as asthma, diabetes, heart problems and others. | |
| Prescription Drugs | Prescription Drugs are covered through Prime Therapeutics, an affiliate of BCBSTX. | |