Blue Cross Blue Shield of Texas
BlueEdge Individual HSA - Plan V - Single Health Insurance Plan
A plan summary of the Blue Cross Blue Shield of Texas BlueEdge Individual HSA - Plan V - Single is detailed out below for both In Network and Out of Network coverage.
| In Network |
Out of Network |
Copay |
25% after Deductible |
40% after Deductible |
Office Visits |
25% |
40% |
| Annual Deductible |
Individual:$1,750 |
Individual:$3,500 |
| Annual Out-Of-Pocket Limit |
Individual:$3,000 |
Individual:$6,000 |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Generic:$10 Preferred Brand:$50 Non-Preferred Brand:$65 after Deductible
|
Generic:$10 Preferred Brand:$50 Non-Preferred Brand:$65 after Deductible
|
| Laboratory & X-Ray |
25% |
40% |
| Annual Physical Exam |
No Charge |
40% |
| Annual OB-GYN Exam |
No Charge |
40% |
Well Baby Care |
No Charge |
40% |
| Outpatient Surgery |
25% |
40% |
| Emergency Room |
25% |
25% |
| Inpatient Hospital |
25% |
40% |
| Ambulance |
25% |
25% |
| Home Health Care |
No Charge after Deductible |
30% |
| Mental Health - Outpatient |
Not Covered |
Not Covered |
| Chiropractic Care |
See Brochure |
See Brochure |
Acupuncture |
Not Covered |
Not Covered |
| Mental Health - Inpatient |
Not Covered
|
Not Covered |
| Chemical Dependency |
Not Covered |
Not Covered |
| Maternity Care |
Not Covered |
Not Covered |
To learn more about your
individual and family
Texas health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.
NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the standard health plan's underwriting guidelines.
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