HMO Blue® Texas Plans
| Health Plan # | Office Visit Copay | In-Hospital Copay | ER Copay | Out of Pocket Maximum | PDP Copay |
|---|---|---|---|---|---|
| RPlan09 | $20 PCP/$20 Specialist | $500 per admission | $75 per visit | $1500/$3000 | PD10 $10/25/40 |
| RPlan11 | $25 PCP/$25 Specialist | $750 per admission | $75 per visit | $2500/$5000 | PD11 $15/30/45 |
| RPlan12 | $30 PCP/$30 Specialist | $1000 per admission | $75 per visit | $3000/$6000 | PD12 $20/35/50 |
| RPlan13 | $10 PCP/$30 Specialist | $350 per admission | $100 per visit | $1500/$3000 | PD10 $10/25/40 |
| RPlan14 | $15 PCP/$35 Specialist | $500 per admission | $125 per visit | $2000/$4000 | PD11 $15/30/45 |
| RPlan15 | $20 PCP/$45 Specialist | $600 per admission | $150 per visit | $2500/$5000 | PD11 $15/30/45 |
| RPlan16 | $25 PCP/$45 Specialist | $1000 per admission | $150 per visit | $3000/$6000 | PD12 $20/35/50 |
| RPlan17 | $30 PCP/$50 Specialist | $1250 per admission | $150 per visit | $3000/$6000 | PD13 $20/40/60 |
| RPlan18 | $35 PCP/$55 Specialist | $1250 per admission | $150 per visit | $4000/$8000 | PD13 $20/40/60 |
| RPlan19 | $40 PCP/$60 Specialist | $1500 per admission | $150 per visit | $4000/$8000 | PD13 $20/40/60 |
