Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024
: MyBlue Health Gold
SM
808 Coverage for: Individual/Family | Plan Type: HMO
Blue 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 6
The 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/bb/ind/bb_ghsd46bftitxo_tx_2024.pdf or by calling 1-888-697-0683. 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 Questions
Answers
Why This Matters:
What is the overall
deductible?
$1,500 Individual/$3,000 Family
Generally, 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?
$8,700 Individual/$17,400 Family
The 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/mbh or
call 1-888-697-0683 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.
Page 2 of 6
*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/ind/bb_ghsd46bftitxo_tx_2024.pdf.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common
Medical Event
Services You May
Need
Participating Providers
(You will pay the least)
Non-Participating
Providers
(You will pay the most)
Limitations, Exceptions, & Other
Important Information
Primary care visit to
treat an injury or
illness
$30/visit; deductible does not apply
Not Covered
Virtual Visits are available. See your benefit
booklet* (Your PCP) for details.
Specialist visit
$60/visit; deductible does not apply
Not Covered
Referral required.
If you visit a health care
provider’s office or clinic
Preventive
care/screening/
immunization
No Charge; deductible does not apply
Not Covered
You 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)
25% coinsurance
Not Covered
Referral may be required. Preauthorization
may also be required; see your benefit
booklet* (Outpatient Lab and X-Ray services)
for details.
If you have a test
Imaging (CT/PET
scans, MRIs)
25% coinsurance
Not Covered
Referral may be required. Preauthorization
may also be required; See your benefit
booklet* (Outpatient Lab and X-Ray services)
for details.
Generic drugs
Retail - Preferred Participating -
$15/prescription
Participating - $15/prescription
Mail - $45/prescription; deductible does not
apply
Not Covered
Brand drugs
(Preferred)
Retail - Preferred Participating -
$30/prescription
Participating - $30/prescription
Mail - $90/prescription; deductible does not
apply
Not Covered
If you need drugs to treat
your illness or condition
More information about
prescription drug coverage
is available at
www.bcbstx.com/rx24/4T
Brand drugs (Non-
preferred)
Retail - Preferred Participating -
$60/prescription
Participating - $60/prescription
Mail - $180/prescription; deductible does not
apply
Not Covered
Limited 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 except for certain FDA-designated
dosing regimens. 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.
Page 3 of 6
*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/ind/bb_ghsd46bftitxo_tx_2024.pdf.
What You Will Pay
Common
Medical Event
Services You May
Need
Participating Providers
(You will pay the least)
Non-Participating
Providers
(You will pay the most)
Limitations, Exceptions, & Other
Important Information
Specialty drugs
$250/prescription; deductible does not apply
Not Covered
Facility fee (e.g.,
ambulatory surgery
center)
25% coinsurance
Not Covered
If you have outpatient
surgery
Physician/surgeon
fees
25% coinsurance
Not Covered
Referral required. Preauthorization may also
be required. For Outpatient Infusion Therapy,
see your benefit booklet* (Outpatient Facility
Services) for details.
Emergency room
care
25% coinsurance
25% coinsurance
None
Emergency medical
transportation
25% coinsurance
25% coinsurance
Preauthorization may be required for non-
emergency transportation; see your benefit
booklet* (Ambulance Services) for details.
If you need immediate
medical attention
Urgent care
$45/visit; deductible does not apply
Not Covered
None
Facility fee (e.g.,
hospital room)
25% coinsurance
Not Covered
Referral required. Preauthorization may also
be required; see your benefit booklet*
(Inpatient Hospital Services) for details.
If you have a hospital stay
Physician/surgeon
fees
25% coinsurance
Not Covered
Referral required. Preauthorization may also
be required; see your benefit booklet*
(Inpatient Professional Services) for details.
Outpatient services
$30/office visit; deductible does not apply;
25% coinsurance for other outpatient services
Not Covered
Preauthorization may be required; see your
benefit booklet* (Behavioral Health Services)
for details.
If you need mental health,
behavioral health, or
substance abuse services
Inpatient services
25% coinsurance
Not Covered
Referral required. Preauthorization may also
be required; see your benefit booklet*
(Behavioral Health Services) for details.
Office visits
Primary Care: $30/initial visit; deductible does
not apply
Specialist: $60/initial visit; deductible does not
apply
Not Covered
Childbirth/delivery
professional services
25% coinsurance
Not Covered
If you are pregnant
Childbirth/delivery
facility services
25% coinsurance
Not Covered
Copayment 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).
Page 4 of 6
*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/bb/ind/bb_ghsd46bftitxo_tx_2024.pdf.
What You Will Pay
Common
Medical Event
Services You May
Need
Participating Providers
(You will pay the least)
Non-Participating
Providers
(You will pay the most)
Limitations, Exceptions, & Other
Important Information
Home health care
25% coinsurance
Not Covered
60 visits/year. Referral required.
Preauthorization may also be required; see
your benefit booklet* (Extended Care
Services) for details.
Rehabilitation
services
$30/visit; deductible does not apply
Not Covered
Habilitation services
$30/visit; deductible does not apply
Not Covered
Separate 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 care
25% coinsurance
Not Covered
25 days/year. Referral required.
Preauthorization may also be required; see
your benefit booklet* (Extended Care
Services) for details.
Durable medical
equipment
25% coinsurance
Not Covered
Referral 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
needs
Hospice services
25% coinsurance
Not Covered
Referral required. Preauthorization may also
be required; see your benefit booklet*
(Extended Care Services) for details.
Children’s eye exam
No Charge; deductible does not apply
Up to a $30
reimbursement is
available; deductible does
not apply
One visit per year. Out-of-Network
reimbursement will not exceed the retail cost.
See your benefit booklet* (Pediatric Vision
Care Benefits) for details.
Children’s glasses
No Charge; deductible does not apply
Up to a $75
reimbursement is
available; deductible does
not apply
One pair of glasses per year. 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.
If your child needs dental or
eye care
Children’s dental
check-up
Not Covered
Not Covered
None
Page 5 of 6
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 and child)
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 programs
Other 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 1 hearing aid per ear every
36 months)
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. You may also contact your state insurance department at 1-800-252-3439 or
Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. 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 OR state Health Insurance Marketplace or SHOP.
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: Texas
Department of Insurance at 1-800-578-4677 or visit https://tdi.texas.gov.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum 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? Not Applicable.
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 1-888-697-0683.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-697-0683.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-888-697-0683.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-697-0683.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 6 of 6
The 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 $1,500
Specialist copayment $60
Hospital (facility) coinsurance 25%
Other coinsurance 25%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost sharing
Deductibles
$1,500
Copayments
$40
Coinsurance
$2,800
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$4,400
The plan’s overall deductible $1,500
Specialist copayment $60
Hospital (facility) coinsurance 25%
Other coinsurance 25%
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 sharing
Deductibles
$900
Copayments
$800
Coinsurance
$0
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is
$1,720
The plan’s overall deductible $1,500
Specialist copayment $60
Hospital (facility) coinsurance 25%
Other coinsurance 25%
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 sharing
Deductibles
$1,500
Copayments
$300
Coinsurance
$100
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$1,900
About 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.
