Blue Choice Preferred Bronze PPO


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Blue Choice Preferred Bronze PPO

Blue Choice Preferred PPO Bronze Plans

Our Rating: Blue Choice Preferred Bronze PPO

Blue Choice Preferred PPO Bronze Plans offer a respectable PPO network of doctors and hospitals and the convenience of never needing a referral to see a specialist. Blue Choice Preferred PPO Plans are coupled with the Blue Choice Preferred PPO network, a smaller version of the “standard” Blue Cross Blue Shield of Illinois PPO network and the largest PPO network BCBSIL offers to individual health plans. If you can accept some reduced hospital and physician choice, a Blue Choice Preferred Bronze PPO plan may be a great option for you. Because the Bronze plans have the same out of pocket maximum as Gold and Silver plans in 2019, it is actually cheaper to purchase a Bronze plan than Gold or Silver if you had a catastrophic event or were hospitalized.

All Blue Choice Bronze plans offer the same set of essential health benefits, quality and amount of care.

Blue Choice Preferred Bronze Plans 202 and 203 HSA compatible plan offered by BCBSIL in 2021, which combined with tax-favored savings account combined allows you to fund health care expenses with pre-tax money.

There are 4 Blue Choice Bronze Plan Options:

 

PPO Network

The Blue PPO Bronze Plans use the Blue Choice Preferred PPO network, a PPO network that includes over half of doctors and hospitals in Illinois.

Key Blue Choice Preferred Bronze® PPO plan features include:
BlueChoice Bronze® may be right for you if you are an individual or family who:

Compare the features, options and costs of Bronze® plans to find the one that’s right for you.

Learn more about valuable member services and features you get when you join the Blue Cross and Blue Shield of Illinois family.

Blue Choice Preferred Bronze PPO

Blue Choice Preferred Bronze PPO 201

Important Questions Answers Why this Matters:
What is the overall deductible?Individual: Participating $6,100; Non-Participating $15,000
Family: Participating $17,100; Non-Participating $45,000
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 and services with a copay are covered before you meet your deductibleThis 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?
NoYou don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
Individual: Participating $8,550; Non-Participating Unlimited
Family: Participating $17,100; Non- Participating Unlimited
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-billed 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.bcbsil.com or call 1-
800-892-2803 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?
No.You can see the specialist you choose without a referral.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

$40/visit; deductible does not apply

50% Coinsurance

Virtual Visits:$40/visit. See your benefit booklet* for details.
Specialist visit

50% Coinsurance

50% Coinsurance

None
Preventive care/screening/immunization

No Charge; deductible does not apply

50% Coinsurance

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.
If you have a testDiagnostic test (x-ray, blood work)

Freestanding Facility: 40%
coinsurance
Hospital: 50% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Imaging (CT / PET scans, MRIs)

Freestanding Facility: 40%
coinsurance Hospital: 50% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about
prescription drug coverage is available here.
Preferred generic drugs

Retail -Preferred –
$10/  prescription
Non-Preferred –
$20/prescription
Mail – $30/prescription;
deductible does not apply

Retail – $20/prescription;
deductible does not apply
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. 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.
All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your
prescription refills, please see your benefit booklet* for details.

Non-preferred generic drugs

Retail -Preferred – $20/ prescription
Non-Preferred – $30/prescription
Mail – $60/prescription;
deductible does not apply

Retail – $30/ prescription;
deductible does not apply
Preferred brand drugs

Preferred – 30% coinsurance
Non-Preferred – 35%
coinsurance

Retail – 35% coinsurance

Non-preferred brand drugs

Preferred – 35% coinsurance
Non-Preferred – 40%
coinsurance

Retail – 40% coinsurance

Preferred specialty drugs

45% coinsurance

45% coinsurance

Non-preferred specialty drugs

50% coinsurance

50% coinsurance

If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)

Freestanding Facility:
$600/visit plus 40%
coinsurance
Hospital: $600/visit plus 50%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
Physician/surgeon fees

$200/visit plus 50%
coinsurance

50% coinsurance

If you need immediate
medical attention
Emergency room care

$1,000/visit plus 50%
coinsurance

$1,000/visit plus 50%
coinsurance

Per occurrence copayment waived upon inpatient admission.
Emergency medical transportation

50% coinsurance

50% coinsurance

Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details.
Urgent care

$60/visit; deductible does not apply

50% coinsurance

None
If you have a hospital
stay
Facility fee (e.g., hospital room)

$850/visit plus 50%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required.

 

Preauthorization required. Preauthorization
penalty: $1,000 or 50% of the eligible charge InNetwork, $500 Out-of-Network.See your benefit
booklet* for details.

Physician/surgeon fee

50% coinsurance

50% coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services50% coinsurance for office
visits; 40% coinsurance for
other outpatient services

50% coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Inpatient services

$850/visit plus 50%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required
If you are pregnantOffice visits

Primary Care: $40;
deductible does not apply
Specialist: 50% coinsurance

50% coinsurance

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional services

50% coinsurance

50% coinsurance

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery facility services

$850/visit plus 50%
coinsurance

$2,000/visit plus 50%
coinsurance

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help
recovering or have other special health needs
Home health care

50% coinsurance

50% coinsurance

Preauthorization may be required.
Rehabilitation services

50% coinsurance

50% coinsurance

Habilitation services

50% coinsurance

50% coinsurance

Skilled nursing care

50% coinsurance

50% coinsurance

Durable medical equipment

50% coinsurance

50% coinsurance

Preauthorization may be required.
Hospice service50% coinsurance

50% coinsurance

Preauthorization may be required.
If your child needs
dental or eye care
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

Reimbursement is available;
deductible does not apply

One pair of glasses per year up to age 19. 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.
Children’s dental check-up

Not Covered

Not Covered

None

*For more information about limitations and exceptions, see the plan or policy document here.

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.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care
  • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
  • Abortion care
  • Bariatric surgery
  • Chiropractic care (limited to 25 visits per calendar year)
  • Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
  • Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
  • Infertility treatment (covered for 4 procedures per benefit period)
  • Private-duty nursing (with the exception of inpatient private duty nursing)
  • Routine foot care (only in connection with diabetes)

Blue Choice Preferred Bronze PPO

Blue Choice Preferred Bronze PPO 202

Important Questions Answers Why this Matters:
What is the overall deductible?Individual: Participating $4,500; Non-Participating $15,000
Family: Participating $13,500; Non-Participating $45,000
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 and services with a copay are covered before you meet your deductibleThis 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?
NoYou don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
Individual: Participating $6,900; NonParticipating Unlimited
Family: Participating $13,800; Non- Participating Unlimited
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-billed 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.bcbsil.com or call 1-
800-892-2803 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?
No.You can see the specialist you choose without a referral.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

40% Coinsurance

50% Coinsurance

Virtual Visits:$40/visit. See your benefit booklet* for details.
Specialist visit

40% Coinsurance

50% Coinsurance

None
Preventive care/screening/immunization

No Charge; deductible does not apply

50% Coinsurance

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.
If you have a testDiagnostic test (x-ray, blood work)

Freestanding Facility: 30%
coinsurance
Hospital: 40% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Imaging (CT / PET scans, MRIs)

Freestanding Facility: 30%
coinsurance Hospital: 40% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about
prescription drug coverage is available here.
Preferred generic drugs

Preferred – 20% coinsurance
Non-Preferred – 25%
coinsurance

Retail – 25% coinsuranceLimited 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. 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.
All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your
prescription refills, please see your benefit booklet* for details.

Non-preferred generic drugs

Preferred – 25% coinsurance
Non-Preferred – 30%
coinsurance

Retail – 30% coinsurance
Preferred brand drugs

Preferred – 30% coinsurance
Non-Preferred – 35%
coinsurance

Retail – 35% coinsurance

Non-preferred brand drugs

Preferred – 35% coinsurance
Non-Preferred – 40%
coinsurance

Retail – 40% coinsurance

Preferred specialty drugs

45% coinsurance

45% coinsurance

Non-preferred specialty drugs

50% coinsurance

50% coinsurance

If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)

Freestanding Facility:
$600/visit plus 30%
coinsurance
Hospital: $600/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization may be required.
For Outpatient Infusion Therapy, see your benefit booklet* for details.
Physician/surgeon fees

$200/visit plus 40%
coinsurance

50% coinsurance

If you need immediate
medical attention
Emergency room care

$1,000/visit plus 40%
coinsurance

$1,000/visit plus 40%
coinsurance

Per occurrence copayment waived upon inpatient admission.
Emergency medical transportation

40% coinsurance

40% coinsurance

Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details
Urgent care

40% coinsurance

50% coinsurance

None.
If you have a hospital
stay
Facility fee (e.g., hospital room)

$850/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required.

 

 

Preauthorization required. Preauthorization
penalty: $1,000 or 50% of the eligible charge In-Network, $500 Out-of-Network. See your benefit booklet* for details.

Physician/surgeon fee

40% Coinsurance

50% Coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services40% coinsurance for office
visits; 30% coinsurance for
other outpatient services

50% coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Inpatient services

$850/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required.
If you are pregnantOffice visits

40% coinsurance

50% coinsurance

Cost sharing does not apply for certain preventive
services. Depending on the type of services,
coinsurance may apply. Maternity care may
include tests and services described elsewhere in
the SBC (i.e. ultrasound)
Childbirth/delivery professional services

40% coinsurance

50% coinsurance

Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)
Childbirth/delivery facility services

$850/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)
If you need help
recovering or have other special health needs
Home health care

40% coinsurance

50% coinsurance

Preauthorization may be required.
Rehabilitation services

40% coinsurance

50% coinsurance

Habilitation services

40% coinsurance

50% coinsurance

Skilled nursing care

40% coinsurance

50% coinsurance

Durable medical equipment

40% coinsurance

50% coinsurance

Preauthorization may be required.
Hospice service40% coinsurance

50% coinsurance

Preauthorization may be required.
If your child needs
dental or eye care
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

Reimbursement is available;
deductible does not apply

One pair of glasses per year up to age 19. 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.
Dental check-up

Not Covered

Not Covered

None

*For more information about limitations and exceptions, see the plan or policy document here.

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.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care
  • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
  • Abortion care
  • Bariatric surgery
  • Chiropractic care (limited to 25 visits per calendar year)
  • Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
  • Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
  • Infertility treatment (covered for 4 procedures per benefit period)
  • Private-duty nursing (with the exception of inpatient private duty nursing)
  • Routine foot care (only in connection with diabetes)

Blue Choice Preferred Bronze PPO

Blue Choice Preferred Bronze PPO 302

Important Questions Answers Why this Matters:
What is the overall deductible?Individual: Participating $6,350; Non-Participating $15,000
Family: Participating $13,500; Non- Participating $45,000
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 and services with a copay are covered before you meet your deductibleThis 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?
NoYou don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
Individual: Participating $6,900; Non-Participating Unlimited
Family: Participating $13,800; Non- Participating Unlimited
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-billed 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.bcbsil.com or call 1-
800-892-2803 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?
No.You can see the specialist you choose without a referral.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

40% coinsurance

50% Coinsurance

Virtual Visits:$40/visit. See your benefit booklet* for details.
Specialist visit

40% coinsurance

50% Coinsurance

None
Preventive care/screening/immunization

No Charge; deductible does not apply

50% Coinsurance

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.
If you have a testDiagnostic test (x-ray, blood work)

Freestanding Facility: 40%
coinsurance
Hospital: 50% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Imaging (CT / PET scans, MRIs)

Freestanding Facility: 30%
coinsurance Hospital: 40% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about
prescription drug coverage is available here.
Preferred generic drugs

Preferred – 20% coinsurance
Non-Preferred – 25%
coinsurance

Retail – 25% coinsuranceLimited 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. 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.
All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your
prescription refills, please see your benefit booklet* for details.

Non-preferred generic drugs

Preferred – 25% coinsurance
Non-Preferred – 30%
coinsurance

Retail – 30% coinsurance
Preferred brand drugs

Preferred – 30% coinsurance
Non-Preferred – 35%
coinsurance

Retail – 35% coinsurance

Non-preferred brand drugs

Preferred – 35% coinsurance
Non-Preferred – 40%
coinsurance

Retail – 40% coinsurance

Preferred specialty drugs

45% coinsurance

45% coinsurance

Non-preferred specialty drugs

50% coinsurance

50% coinsurance

If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)

Freestanding Facility:
$600/visit plus 30%
coinsurance
Hospital: $600/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
Physician/surgeon fees

$200/visit plus 40%
coinsurance

50% coinsurance

If you need immediate
medical attention
Emergency room care

$1,000/visit plus 40%
coinsurance

$1,000/visit plus 40%
coinsurance

Per occurrence copayment waived upon inpatient admission.
Emergency medical transportation

40% coinsurance

40% coinsurance

Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details.
Urgent care

40% coinsurance

40% coinsurance

None
If you have a hospital
stay
Facility fee (e.g., hospital room)

$850/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required.

 

Preauthorization required. Preauthorization
penalty: $1,000 or 50% of the eligible charge InNetwork, $500 Out-of-Network.See your benefit
booklet* for details.

Physician/surgeon fee

40% coinsurance

40% coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services40% coinsurance for office
visits; 30% coinsurance for
other outpatient services

50% coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Inpatient services

$850/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required
If you are pregnantOffice visits

40% coinsurance

50% coinsurance

Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional services

40% coinsurance

50% coinsurance

Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery facility services

$850/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help
recovering or have other special health needs
Home health care

40% coinsurance

50% coinsurance

Preauthorization may be required.
Rehabilitation services

40% coinsurance

50% coinsurance

Habilitation services

40% coinsurance

50% coinsurance

Skilled nursing care

40% coinsurance

50% coinsurance

Durable medical equipment

40% coinsurance

50% coinsurance

Preauthorization may be required.
Hospice service40% coinsurance

50% coinsurance

Preauthorization may be required.
If your child needs
dental or eye care
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

Reimbursement is available;
deductible does not apply

One pair of glasses per year up to age 19. 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.
Children’s dental check-up

Not Covered

Not Covered

None

*For more information about limitations and exceptions, see the plan or policy document here.

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.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care
  • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
  • Abortion care
  • Bariatric surgery
  • Chiropractic care (limited to 25 visits per calendar year)
  • Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
  • Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
  • Infertility treatment (covered for 4 procedures per benefit period)
  • Private-duty nursing (with the exception of inpatient private duty nursing)
  • Routine foot care (only in connection with diabetes)

Blue Choice Preferred Bronze PPO

Blue Choice Preferred Bronze PPO 502

Important Questions Answers Why this Matters:
What is the overall deductible?Individual: Participating $5,000; Non-Participating $15,000
Family: Participating $13,800; Non-Participating $45,000
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 and services with a copay are covered before you meet your deductibleThis 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?
NoYou don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
Individual: Participating $6,900; Non-Participating Unlimited
Family: Participating $13,800; Non- Participating Unlimited
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-billed 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.bcbsil.com or call 1-
800-892-2803 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?
No.You can see the specialist you choose without a referral.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

50% coinsurance

50% Coinsurance

Virtual Visits: 50% coinsurance. See your benefit booklet* for details.
Specialist visit

50% coinsurance

50% Coinsurance

None
Preventive care/screening/immunization

No Charge; deductible does not apply

50% Coinsurance

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.
If you have a testDiagnostic test (x-ray, blood work)

Freestanding Facility: 40%
coinsurance
Hospital: 50% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Imaging (CT / PET scans, MRIs)

Freestanding Facility: 40%
coinsurance Hospital: 50% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about
prescription drug coverage is available here.
Preferred generic drugs

Preferred – 20% coinsurance
Non-Preferred – 25%
coinsurance

Retail – 25% coinsuranceLimited 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. 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.
All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your
prescription refills, please see your benefit booklet* for details.

Non-preferred generic drugs

Preferred – 25% coinsurance
Non-Preferred – 30%
coinsurance

Retail – 30% coinsurance
Preferred brand drugs

Preferred – 30% coinsurance
Non-Preferred – 35%
coinsurance

Retail – 35% coinsurance

Non-preferred brand drugs

Preferred – 35% coinsurance
Non-Preferred – 40%
coinsurance

Retail – 40% coinsurance

Preferred specialty drugs

45% coinsurance

45% coinsurance

Non-preferred specialty drugs

50% coinsurance

50% coinsurance

If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)

Freestanding Facility:
$600/visit plus 40%
coinsurance
Hospital: $600/visit plus 40%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
Physician/surgeon fees

$200/visit plus 50%
coinsurance

50% coinsurance

If you need immediate
medical attention
Emergency room care

$1,000/visit plus 50%
coinsurance

$1,000/visit plus 50%
coinsurance

Per occurrence copayment waived upon inpatient admission.
Emergency medical transportation

50% coinsurance

50% coinsurance

Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details.
Urgent care

50% coinsurance

50% coinsurance

None
If you have a hospital
stay
Facility fee (e.g., hospital room)

$850/visit plus 50%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required.

 

Preauthorization required. Preauthorization
penalty: $1,000 or 50% of the eligible charge In-Network, $500 Out-of-Network. See your benefit booklet* for details.

Physician/surgeon fee

50% coinsurance

50% coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services50% coinsurance for office
visits; 40% coinsurance for
other outpatient services

50% coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Inpatient services

$850/visit plus 50%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required
If you are pregnantOffice visits

50% coinsurance

50% coinsurance

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, may apply. Maternity care may include tests and services described elsewhere in the SBC
(i.e. ultrasound).
Childbirth/delivery professional services

50% coinsurance

50% coinsurance

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, may apply. Maternity care may include tests and services described elsewhere in the SBC
(i.e. ultrasound).
Childbirth/delivery facility services$850/visit plus 50% coinsurance$2,000/visit plus 50%
coinsurance
Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, may apply. Maternity care may include tests and services described elsewhere in the SBC
(i.e. ultrasound).
If you need help
recovering or have other special health needs
Home health care

50% coinsurance

50% coinsurance

Preauthorization may be required.
Rehabilitation services

50% coinsurance

50% coinsurance

Habilitation services

50% coinsurance

50% coinsurance

Skilled nursing care

50% coinsurance

50% coinsurance

Durable medical equipment

50% coinsurance

50% coinsurance

Preauthorization may be required.
Hospice service50% coinsurance

50% coinsurance

Preauthorization may be required.
If your child needs
dental or eye care
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

Reimbursement is available;
deductible does not apply

One pair of glasses per year up to age 19. 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.
Children’s dental check-up

Not Covered

Not Covered

None

*For more information about limitations and exceptions, see the plan or policy document here.

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.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care
  • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
  • Abortion care
  • Bariatric surgery
  • Chiropractic care (limited to 25 visits per calendar year)
  • Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
  • Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
  • Infertility treatment (covered for 4 procedures per benefit period)
  • Private-duty nursing (with the exception of inpatient private duty nursing)
  • Routine foot care (only in connection with diabetes)