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Coverage and Eligibility

Blue Cross and Blue Shield of Texas (BCBSTX) health plans cover medically necessary health benefits, including physician services, hospitalization and emergency services.

In addition, we have put in place working solutions to help our members get the care they need during these uncertain times.

With a BCBSTX health plan, our members have access to care for COVID-19 related health issues. Members can use doctors, labs and facilities in their BCBSTX health plan’s provider network for:

  • Tests to diagnose COVID-19
  • COVID-19 testing-related doctor’s visits
  • COVID-19 treatment

In response to the pandemic, BCBSTX made some temporary changes impacting coverage for various services. Some of these changes will end with the end of the public health emergency. Some may end sooner, depending on the member’s plan. To understand what is currently in effect, please view effective coverage dates.

COVID-19 Vaccines

With a BCBSTX health plan, members have access to COVID-19 vaccines at no cost to them. Members should talk with their doctors about when they should get vaccinated once available and discuss any questions they have about the vaccines.

While most plans cover COVID-19 vaccines at no cost, some self-funded groups do not cover preventive services, including COVID-19 vaccines. Members who are unsure what their plan covers should contact their company’s benefits administrator or call BCBSTX Customer Service at the number listed on their member ID card.

Cost-Sharing Waived

To make it easier for our members to get the care and treatment they need amid the COVID-19 outbreak, we are temporarily waiving member cost-sharing, including copays, deductibles and coinsurance, related to testing for COVID-19.

  • For testing: Members will not pay copay, deductible or coinsurance for medically necessary lab tests to diagnose for COVID-19 until the end of the federal public health emergency (as required by the Families First Coronavirus Response Act).
  • For testing-related visits: Out-of-pocket costs for medically necessary care are covered when using network providers in any setting until the end of the federal public health emergency (as required by the Families First Coronavirus Response Act).
  • For treatment: Out-of-pocket costs were covered for treatment received April 1, 2020, through Dec. 31, 2020, at network facilities and for out-of-network emergencies. As of January 1, 2021, members are responsible for the out-of-pocket costs associated with claims for treatment.

The policy applies to members in these plans:

  • Fully insured groups
  • Individual and family
  • Medicare (excluding Part D)
  • Medicare Supplement
  • Medicaid
  • HSA qualified high-deductible health plans
  • Self-funded and split-funded groups that have opted in

Telehealth Expanded

Cost-share waivers on telehealth or telemedicine services for fully insured group, retail, Medicare (not Part D) and Medicare Supplement plans ended on Dec. 31, 2020. That means copays, deductibles and coinsurance now apply.

Telehealth cost-share waivers for fully insured group, retail, Medicare (not Part D) and Medicare Supplement plans ended on Dec. 31, 2020. That means copays, deductibles and coinsurance now apply.

Self-funded customers have some choices about how we administer COVID-19 treatment coverage for their employees. Benefits for members of self-funded plans may vary. They should call BCBSTX Customer Service at the number listed on their member ID card for more information.

Prescription Coverage

Members with pharmacy benefits through Prime Therapeutics®** can get an early refill on many current prescriptions. They can also sign up for mail-order delivery (up to a 90-day supply of covered non-specialty medications) with AllianceRx Walgreens Prime or by calling Customer Service at the number on their BCBSTX member ID card.

Members with Group Medicare Advantage and Group MedicareRx (PDP) plans can get 90-day fills through mail order.

Prior Authorization

For Transfers.  Prior authorization from an inpatient hospital to an in-network medically appropriate, post-acute site of care such as long-term acute care hospitals and skilled nursing facilities will not be required through Feb. 28, 2021. This will help promote availability of acute care capacity for COVID-19 patients during this public health emergency. It also allows our members to continue to access medically necessary care. Transfers to a behavioral health facility will still require prior authorization.

On Previously Approved Elective Surgeries, Procedures and Therapies.  We extended approvals on existing prior authorizations for non-emergent elective surgeries, procedures, therapies and home visits, if the service was provided by Dec. 31, 2020. This applies to services that were originally approved or scheduled between Jan. 1, 2020 and June 30, 2020.

Relaxed Eligibility Requirements

Employers can maintain employees who were enrolled as of March 20, 2020 through Sept. 30, 2020, regardless of the eligibility definition stated in their plan or the BPA. This includes reduced work hours, furlough, leave of absence or layoffs. This flexibility does not apply to those who are newly electing coverage via a special enrollment period.

See what is being communicated directly to our members about these coverage changes.

*Blue Cross and Blue Shield of Texas (BCBSTX) contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. Myprime.com is an online resource offered by Prime Therapeutics.