Return to flip book view

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023 – 12/31/2023 : G664ADT Blue Advantage Gold HMOSM 817 Coverage for: Individual/Family | Plan Type: HMOBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-877-299-2377. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overall deductible?$2,000 Individual/$6,000 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?Yes. In-Network Preventive Health Care services, services with a copayment, and prescription drugs are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.Are there other deductibles for specific services?No.You don’t have to meet deductibles for specific services.What is the out-of-pocket limit for this plan?$6,000 Individual/$17,100 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.What is not included in the out-of-pocket limit?Premiums, balance-billing charges, and health care this plan doesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if you use a network provider?Yes. See www.bcbstx.com/go/bahmo or call 1-877-299-2377 for a list of Participating providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.Do you need a referral to see a specialist?Yes.This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.SLMR GHSG15BAVSTXO2023E01012023 0000021 0858C :doireP egarevo 0 3202/10/1 -1 3202/13/2C :rof egarevo I ylimaF + laudividn | P :epyT nal H OM

Page 2 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationPrimary care visit to treat an injury or illness$30/visit; deductible does not apply Not CoveredVirtual Visits are available. See your benefit booklet* (Your PCP) for details.Specialist visit$60/visit; deductible does not apply Not CoveredReferral required.If you visit a health care provider’s office or clinicPreventive care/screening/ immunizationNo Charge; deductible does not apply Not CoveredYou may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.Diagnostic test (x-ray, blood work)20% coinsuranceNot CoveredReferral may be required. Preauthorization may also be required; see your benefit booklet* (Outpatient Lab and X-Ray services) for details.If you have a testImaging (CT/PET scans, MRIs) $250/test; deductible does not apply Not CoveredReferral may be required. Preauthorization may also be required; see your benefit booklet* (Outpatient Lab and X-Ray services) for details.Preferred generic drugsRetail - Preferred Participating - No ChargeParticipating - $10/prescriptionMail - No Charge; deductible does not applyNot CoveredNon-preferred generic drugsRetail - Preferred Participating - $10/prescription Participating - $20/prescription Mail - $30/prescription; deductible does not apply Not CoveredIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at www.bcbstx.com/rx23/6TPreferred brand drugsRetail - Preferred Participating - $50/prescription Participating - $70/prescription Mail - $150/prescription; deductible does not apply Not CoveredLimited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Certain drugs require approval before they will be covered. Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the prescription.0000021 0858

Page 3 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationNon-preferred brand drugsRetail - Preferred Participating - $100/prescription Participating - $120/prescription Mail - $300/prescription; deductible does not apply Not CoveredPreferred specialty drugs$150/prescription; deductible does not apply Not CoveredNon-preferred specialty drugs$250/prescription; deductible does not applyNot CoveredFacility fee (e.g., ambulatory surgery center)$100/visit plus 20% coinsuranceNot CoveredIf you have outpatient surgery Physician/surgeon fees20% coinsuranceNot CoveredReferral required. Preauthorization may also be required. For Outpatient Infusion Therapy, see your benefit booklet* (Outpatient Facility Services) for details.Emergency room care$300/visit plus 20% coinsurance$300/visit plus 20% coinsuranceCopayment waived if admitted.Emergency medical transportation20% coinsurance20% coinsurancePreauthorization may be required for non-emergency transportation; see your benefit booklet* (Ambulance Services) for details.If you need immediate medical attentionUrgent care$75/visit; deductible does not applyNot CoveredNoneFacility fee (e.g., hospital room)$150/visit plus 20% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Hospital Services) for details.If you have a hospital stayPhysician/surgeon fees20% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Inpatient Professional Services) for details.Outpatient services$30/office visit; deductible does not apply;20% coinsurance for other outpatient servicesNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Behavioral Health Services) for details.If you need mental health, behavioral health, or substance abuse servicesInpatient services$150/visit plus 20% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Behavioral Health Services) for details.0000021 0858

Page 4 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationOffice visitsPrimary Care: $30/initial visit Specialist: $60/initial visit; deductible does not apply Not CoveredChildbirth/delivery professional services20% coinsuranceNot CoveredIf you are pregnantChildbirth/delivery facility services$150/visit plus 20% coinsuranceNot CoveredCopayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).Home health care20% coinsuranceNot Covered60 visits/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Rehabilitation services20% coinsuranceNot CoveredHabilitation services20% coinsuranceNot CoveredSeparate 35-visit maximum per benefit period for Habilitation and Rehabilitation services, including chiropractic care. Referral required. Preauthorization may also be required; see your benefit booklet* (Rehabilitation Services and Habilitation Services) for details.Skilled nursing care20% coinsuranceNot Covered25 days/year. Referral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.Durable medical equipment20% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Durable Medical Equipment) for details.If you need help recovering or have other special health needsHospice services20% coinsuranceNot CoveredReferral required. Preauthorization may also be required; see your benefit booklet* (Extended Care Services) for details.If your child needs dental or eye careChildren’s eye examNo Charge; deductible does not applyUp to a $30 reimbursement is available; deductible does not applyOne visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.0000021 0858

Page 5 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023.What You Will PayCommon Medical EventServices You May NeedParticipating Providers (You will pay the least)Non-Participating Providers (You will pay the most)Limitations, Exceptions, & Other Important InformationChildren’s glassesNo Charge; deductible does not applyUp to a $75 reimbursement is available; deductible does not applyOne pair of glasses every 12 months. Reimbursement for frames, lenses, and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.Children’s dental check-up30% coinsurance30% coinsuranceOral exams are limited to two every benefit period. Benefits for periodic and comprehensive oral evaluations are limited to a combined maximum of two every 12 months. See your benefit booklet* (Pediatric Dental Benefits Rider) for details.Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Abortion (except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed) Acupuncture Bariatric surgery Cosmetic surgery (except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases when medically necessary) Dental care (Adult) Infertility treatment (diagnosis and treatment covered; in vitro not covered) Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing (unless medically necessary) Routine eye care (Adult) Routine foot care (except when medically necessary) Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care (35 visits/year combined with habilitation and rehabilitation services) Hearing aids (limited to one hearing aid per ear every 36 months)0000021 0858

Page 6 of 7*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2023.Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at Blue Cross and Blue Shield of Texas at 1-888-697-0683 or visit www.bcbstx.com. For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-877-299-2377.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-877-299-2377.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377.To see examples of how this plan might cover costs for a sample medical situation, see the next section.0000021 0858

Page 7 of 7The plan would be responsible for the other costs of these EXAMPLE covered services.Peg is Having a Baby(9 months of in-network pre-natal care and a hospital delivery)Mia’s Simple Fracture(in-network emergency room visit and follow up care)Managing Joe’s Type 2 Diabetes(a year of routine in-network care of a well-controlled condition)  The plan’s overall deductible $2,000 Specialist copayment $60 Hospital (facility) copayment/coinsurance$150+20% Other coinsurance 20%This EXAMPLE event includes services like: Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia) Total Example Cost$12,700 In this example, Peg would pay:Cost sharingDeductibles$2,000Copayments$500Coinsurance$2,000What isn’t coveredLimits or exclusions$60The total Peg would pay is$4,560 The plan’s overall deductible $2,000 Specialist copayment $60 Hospital (facility) copayment/coinsurance$150+20% Other coinsurance 20%This EXAMPLE event includes services like: Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugs Durable medical equipment (glucose meter) Total Example Cost$5,600 In this example, Joe would pay:Cost sharingDeductibles$900Copayments$700Coinsurance$0What isn’t coveredLimits or exclusions$20The total Joe would pay is$1,620 The plan’s overall deductible $2,000 Specialist copayment $60 Hospital (facility) copayment/coinsurance$150+20% Other coinsurance 20%This EXAMPLE event includes services like: Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example Cost$2,800 In this example, Mia would pay:Cost sharingDeductibles$2,000Copayments$600Coinsurance$10What isn’t coveredLimits or exclusions$0The total Mia would pay is$2,610About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. 0000021 0858

0000021 0858

0000021 0858

0000021 0858