Texas health plan · 2025

Blue Advantage Bronze HMO℠ 204 · 33602TX0460723

Blue Cross Blue Shield of Texas offers this marketplace health insurance plan (Plan ID 33602TX0460723) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Expanded Bronze Plan type: HMO CSR: Zero Cost Sharing Plan Variation Issuer: Blue Cross Blue Shield of Texas
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 100.00% (0.00% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$275 – $1079

Before subsidies

Estimate after subsidies

Deductible

$0

$0 per group

See deductible details

Max out-of-pocket

$0

$0 per group

Review MOOP rules

Office visits

Primary care $0.00, 0.00%
Specialist $0.00, 0.00%
HSA Not eligible

Drug tiers

Generic $0.00, 0.00%
Preferred brand $0.00, 0.00%

View formulary tiers

$377 / mo before subsidies

≈ $4523 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1194 / mo before subsidies

≈ $14332 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1446 / mo before subsidies

≈ $17358 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$919 / mo before subsidies

≈ $11031 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

$0.00, 0.00%

Emergency Room Services

$0.00, 0.00%

Durable Medical Equipment

$0.00, 0.00%

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Texas). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Zero Cost Sharing Plan Variation plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

$0.00, 0.00%

Emergency Room Services

$0.00, 0.00%

Durable Medical Equipment

$0.00, 0.00%

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 33602TX0460723
Coverage year 2025
State Texas
Issuer Blue Cross Blue Shield of Texas
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 33602TX0460723-02
Available variants

Standard Off Exchange Plan · 33602TX0460723-00

Standard On Exchange Plan · 33602TX0460723-01

Open to Indians below 300% FPL · 33602TX0460723-02

Open to Indians above 300% FPL · 33602TX0460723-03
Last plan update Sat, 11 Jan 2025 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in Texas 96
PCPs in Texas N/A
Telehealth support Data pending
Nationwide providers 336
96 doctors statewide

Provider network(s)

Providers Texas All US states
All 96 336
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 69 217

Drug coverage overview

3,967 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
NON-PREFERRED-GENERIC 2,316
NON-PREFERRED-SPECIALTY 915
NON-PREFERRED-BRAND 736
Prior authorization Drugs
Required 952
Not Required 3,015
Step therapy Drugs
Required 29
Not Required 3,938
Quantity limits Drugs
Has Limit 1,678
No Limit 2,289

Customer highlights

What stands out for members

  • Issuer: Blue Cross Blue Shield of Texas · Plan ID 33602TX0460723 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 33602TX0460723-02 (Open to Indians below 300% FPL) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 35.0 Visit(s) per Benefit Period

Muscle manipulations included in Rehabilitation and Habilitation limits.

Exclusions: nan

Diabetes Education

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Home Health Care Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Benefit Period

nan

Exclusions: nan

Laboratory Outpatient and Professional Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

Exclusions: nan

Rehabilitative Speech Therapy

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Specialist Visit

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Urgent Care Centers or Facilities

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

X-rays and Diagnostic Imaging

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 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.

Exclusions: nan

Dialysis

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Durable Medical Equipment

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Emergency Room Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network $0.00, 0.00%

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.

Exclusions: nan

Emergency Transportation/Ambulance

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network $0.00, 0.00%

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.

Exclusions: nan

Hospice Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 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.

Exclusions: nan

Inpatient Physician and Surgical Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Member cost share may increase when using a setting other than office. 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.

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Member cost share may increase when using a setting other than office.

Exclusions: nan

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 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.

Exclusions: nan

Outpatient Rehabilitation Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 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.

Exclusions: nan

Radiation

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Skilled Nursing Facility

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 25.0 Days per Benefit Period

nan

Exclusions: nan

Substance Abuse Disorder Inpatient Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Member cost share may increase when using a setting other than office. 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.

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Member cost share may increase when using a setting other than office.

Exclusions: nan

Transplant

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 1.0 Item(s) per 3 Years

Coverage is limited to 1 hearing aid per ear every 36 month

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.

Exclusions: nan

Routine Eye Exam for Children

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 1.0 Visit(s) per Benefit Period

When purchasing Out of Network, reimbursements are available. See benefit book for details.

Exclusions: nan

Well Baby Visits and Care

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

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.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Non-Preferred Brand Drugs

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

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.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Preferred Brand Drugs

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

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.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Specialty Drugs

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

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.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

Coverage details pending

Covered for Preventive and Diabetes services only.

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

nan

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

When services are provided in an office setting, cost shares may vary. Please see benefit booklet for details.

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

Cosmetic Surgery

Coverage details pending

Except when medically necessary.

Exclusions: nan

Eye Glasses for Children

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 1.0 Item(s) per Benefit Period

All frames will first apply towards the allowance. Discount will apply on remaining balance, after the allowance. See benefit book for details

Exclusions: nan

Gender Affirming Care

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Habilitation Services

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 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.

Exclusions: nan

Infertility Treatment

Coverage details pending

nan

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

Coverage details pending

nan

Exclusions: Not covered unless medically necessary.

Reconstructive Surgery

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Routine Eye Exam (Adult)

Coverage details pending

nan

Exclusions: nan

Routine Foot Care

Coverage details pending

Covered when medically necessary

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

$0.00, 0.00%
Tier 1 in-network $0.00, 0.00%
Tier 2 in-network $0.00, 0.00%
Out-of-network 100.00%

nan

Exclusions: 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.

Variant attributes

Blue Advantage Bronze HMO℠ 204 · Variant 33602TX0460723-02

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Zero Cost Sharing Plan Variation

HIOS Product ID

33602TX046

Metal Level

Expanded Bronze

Plan ID (Standard Component ID with Variant)

33602TX0460723-02

Plan Marketing Name

Blue Advantage Bronze HMO℠ 204

Plan Variant Marketing Name

Blue Advantage Bronze HMO℠ 204

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

33602

Issuer Marketplace Marketing Name

Blue Cross and Blue Shield of Texas

Market Coverage

Individual

Multiple In Network Tiers

Yes

National Network

No

Network ID

TXN009

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.

Service Area ID

TXS199

State Code

TX

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

1.0

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$0

SBC Scenario, Having a Baby, Deductible

$0

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$0

SBC Scenario, Having Diabetes, Deductible

$0

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$0

SBC Scenario, Treatment of a Simple Fracture, Deductible

$0

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group

$0 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person

$0 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual

$0

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

0.00%

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance

0.00%

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$0 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$0 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$0

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group

$0 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person

$0 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual

$0

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

$0 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

$0 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

$0

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

TXF017

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

EHB Percent of Total Premium

1.0

First Tier Utilization

85%

Import Date

2025-01-11 00:01:52

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

Yes

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

HMO

QHP/Non QHP

Both

Second Tier Utilization

15%

Source Name

HIOS

Specialist Requiring a Referral

Referrals are required for some services. Please check with your Medical Group for details.

Plan ID

33602TX0460723

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group

$0 per group

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person

$0 per person

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual

$0

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group

$0 per group

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person

$0 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$0

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group

$0 per group

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person

$0 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual

$0

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group

$0 per group

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person

$0 per person

Combined Medical and Drug EHB Deductible, Out of Network, Individual

$0

Unique Plan Design

No

Wellness Program Offered

No

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Texas?

Blue Advantage Bronze HMO℠ 204 (33602TX0460723) is a Expanded Bronze HMO from Blue Cross Blue Shield of Texas in Texas for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Blue Advantage Bronze HMO℠ 204 support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Blue Advantage Bronze HMO℠ 204 HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Child.

Does Blue Advantage Bronze HMO℠ 204 support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with Blue Advantage Bronze HMO℠ 204?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy.

Is there out-of-country coverage for Blue Advantage Bronze HMO℠ 204?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: No coverage for any services, supplies or drugs received by a Member outside of the United States, except for Emergency Care

Does Blue Advantage Bronze HMO℠ 204 cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Coverage outside our service area is available for Emergency and Urgent Care services only.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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