Blue Choice Preferred Bronze PPO


Blue Cross BlueShield of Illinois
Free Online Quote

Find a BlueChoice Preferred PPO Doctor

Blue Choice Preferred PPO Bronze Plans

Our Rating:

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, Blue Choice Preferred Silver PPO may be a great option for you. All Blue Choice Preferred Silver PPO plans offer the same set of essential health benefits, quality and amount of care.

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

Blue Choice Preferred Bronze Plans 105 and 106 are HSA compatible plans, 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:
  • Bronze Plan 105 – $5,000 individual deductible and 60% coinsurance
  • Bronze Plan 106 – $6,500 individual deductible and 100% coinsurance
  • Bronze Plan 107 – $6,750 individual deductible and 80% coinsurance, 1 $0 office visit copay
  • Bronze Plan 108 – $7,150 individual deductible and 60% coinsurance

 

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 105

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Individual:
Participating $5,000
Non-Participating $15,000
Family:
Participating $13,100
Non-Participating $45,000
Doesn’t apply to preventive care
& certain copayments.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 or other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. Individual:
Participating $6,550
Non-Participating Unlimited
Family:
Participating $13,100
Non-Participating Unlimited

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

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.

Does this plan use a network of providers?

Yes. See http://www.bcbsil.com or call
1-800-538-8833 for a list of Participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Common Medical Event

Services You May Need

Your cost if you use
a Participating
Provider

Your cost if you use
a Non-Participating
Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

40% coinsurance

50% coinsurance

No benefits will be provided for services which are not, in the reasonable judgment of Blue Cross and Blue Shield, medically necessary.

Specialist visit

40% coinsurance

50% coinsurance

—none—

Other practitioner office visit

40% coinsurance

50% coinsurance

Acupuncture not covered. Chiropractic and Osteopathic Manipulation are limited to 25 visits per calendar year.

Preventive care/screening/immunization

No Charge

50% coinsurance

—none—

If you have a test

Diagnostic test (x-ray, blood work)

40% coinsurance

50% coinsurance

—none—

Imaging (CT / PET scans, MRIs)

40% coinsurance

50% coinsurance

—none—

If you need drugs to
treat your illness or
condition

More information about
prescription drug
coverage is available
here

Formulary generic drugs

30% coinsurance/
25% coinsurance

35% coinsurance

Lower coinsurance applies at preferred
Participating pharmacies. Retail covers a 30 day supply and home delivery covers a 90 day supply. Certain women’s preventive services will be covered with no cost to the member.
For a full list of these prescriptions and/or services, please contact
Customer Service. Non-Participating home delivery is not covered.
Non-Participating specialty drug coverage is limited to certain medications that are clarified in the prescription drug rider. For Non-Participating drug provider, you are responsible for 50% of the eligible amount after the coinsurance. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Generic drugs are not subject to the deductible.

Non-formulary generic drugs

30% coinsurance/
25% coinsurance

35% coinsurance

Formulary brand drugs

40% coinsurance/
40% coinsurance

50% coinsurance

Non-formulary brand drugs

50% coinsurance/
50% coinsurance

50% coinsurance

Specialty drugs

50% coinsurance

50% coinsurance

If you have outpatient
surgery

Facility fee (e.g., ambulatory surgery center)

40% coinsurance

50% coinsurance

Abortions not covered, except where a pregnancy is the result of rape or incest, or for a pregnancy which, as
Certified by a physician, places the woman in danger of death unless an abortion is performed.

Physician/surgeon fees

30% coinsurance

50% coinsurance

If you need immediate
medical attention

Emergency room services

30% coinsurance

30% coinsurance

—none—

Emergency medical transportation

30% coinsurance

30% coinsurance

Ground and air transportation covered.

Urgent care

30% coinsurance

50% coinsurance

—none—

If you have a hospital
stay

Facility fee (e.g., hospital room)

30% coinsurance

50% coinsurance

Inpatient Services: Participating (Par),
member may be balance billed if preauthorization not received within
15 days prior. Non-Participating (Non-Par), $500 penalty if not preauthorized 2 business days prior.

Physician/surgeon fee

30% coinsurance

50% coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs

Mental/Behavioral health outpatient services

30% coinsurance

50% coinsurance

Pre-authorization is required for Psychological testing; Neuropsychological testing;
Electroconvulsive therapy; Repetitive Transcranial magnetic Stimulation; and Intensive Outpatient Treatment.
Inpatient Services: Par, member may
be balance billed if preauthorization not received within 15 days prior.
Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will
be responsible for the first $1,000 or
50%, whichever is less, if not preauthorized one business day prior. Non-Par, $500 penalty if not preauthorized one business day prior.

Mental/Behavioral health inpatient services

30% coinsurance

50% coinsurance

Substance use disorder outpatient services

30% coinsurance

50% coinsurance

Substance use disorder inpatient services

30% coinsurance

50% coinsurance

If you are pregnant

Prenatal and postnatal care

30% coinsurance

50% coinsurance

–none—

Delivery and all inpatient services

30% coinsurance

50% coinsurance

If you need help
recovering or have other special health needs

Home health care

30% coinsurance

50% coinsurance

Inpatient Services: Par, member may
be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not preauthorized one business day prior.
Non-Par, $500 penalty if not preauthorized one business day prior.

Rehabilitation services

30% coinsurance

50% coinsurance

Habilitation services

30% coinsurance

50% coinsurance

Skilled nursing care

30% coinsurance

50% coinsurance

Durable medical equipment

30% coinsurance

50% coinsurance

Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).

Hospice service

30% coinsurance

50% coinsurance

Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.

If your child needs
dental or eye care

Eye exam

No Charge

Covered

One visit per year. Reimbursed up to
$30 out-of-network. See benefit booklet for network details.

Glasses

Covered

Covered

One pair of glasses per year. Reimbursed up to $45 out-of-network.
See benefit booklet for network details.

Dental check-up

Not Covered

Not Covered

—none—

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Abortions (Except where a pregnancy is the result of rape or incest, or for a pregnancy which, as certified by a physician, places the woman in danger of death unless an abortion is performed)
  • Acupuncture
  • Dental Care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
  • 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 (Two covered every 36 months for children or bone anchored)
  • Infertility treatment
  • Private-duty nursing (With the exception of inpatient private duty nursing)
  • Routine foot care (Only in connection with diabetes)

Blue Choice Preferred Bronze PPO 106

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Individual:
Participating $6,000
Non-Participating $15,000
Family:
Participating $13,100
Non-Participating $45,000
Doesn’t apply to preventive care
& certain copayments.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 or other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. Individual:
Participating $6,000
Non-Participating Unlimited
Family:
Participating $13,100
Non-Participating Unlimited

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

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.

Does this plan use a network of providers?

Yes. See http://www.bcbsil.com or call 1-800-538-8833 for a list of Participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Common Medical Event

Services You May Need

Your cost if you use
a Participating
Provider

Your cost if you use
a Non-Participating
Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

No Charge

50% coinsurance

No benefits will be provided for services which are not, in the reasonable judgment of Blue Cross and Blue Shield, medically necessary.

Specialist visit

No Charge

50% coinsurance

—none—

Other practitioner office visit

No Charge

50% coinsurance

Acupuncture not covered. Chiropractic and Osteopathic Manipulation are limited to 25 visits per calendar year.

Preventive care/screening/immunization

No Charge

50% coinsurance

—none—

If you have a test

Diagnostic test (x-ray, blood work)

No Charge

50% coinsurance

—none—

Imaging (CT / PET scans, MRIs)

No Charge

50% coinsurance

—none—

If you need drugs to
treat your illness or
condition

More information about
prescription drug coverage is available here.

Formulary generic drugs

No Charge

No Charge

Retail covers a 30 day supply and home delivery covers a 90 day supply. Non-Participating home delivery is not covered. Non-Participating specialty drug coverage is limited to certain medications that are clarified in the prescription drug rider. Generic drugs are not subject to the deductible.

Non-formulary generic drugs

No Charge

No Charge

Formulary brand drugs

No Charge

No Charge

Non-formulary brand drugs

No Charge

No Charge

Specialty drugs

No Charge

No Charge

If you have outpatient
surgery

Facility fee (e.g., ambulatory surgery center)

No Charge

50% coinsurance

Abortions not covered, except where a pregnancy is the result of rape or incest, or for a pregnancy which, as
Certified by a physician, places the woman in danger of death unless an abortion is performed.

Physician/surgeon fees

No Charge

50% coinsurance

If you need immediate
medical attention

Emergency room services

No Charge

No Charge

—none—

Emergency medical transportation

No Charge

No Charge

Ground and air transportation covered.

Urgent care

No Charge

50% coinsurance

—none—

If you have a hospital
stay

Facility fee (e.g., hospital room)

No Charge

50% coinsurance

Inpatient Services: Participating (Par),
member may be balance billed if preauthorization not received within
15 days prior. Non-Participating (Non-Par), $500 penalty if not preauthorized 2 business days prior.

Physician/surgeon fee

No Charge

50% coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs

Mental/Behavioral health outpatient services

No Charge

50% coinsurance

Pre-authorization is required for Psychological testing; Neuropsychological testing;
Electroconvulsive therapy; Repetitive Transcranial magnetic Stimulation; and Intensive Outpatient Treatment.
Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior.
Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will
be responsible for the first $1,000 or
50%, whichever is less, if not preauthorized one business day prior. Non-Par, $500 penalty if not preauthorized one business day prior.

Mental/Behavioral health inpatient services

No Charge

50% coinsurance

Substance use disorder outpatient services

No Charge

50% coinsurance

Substance use disorder inpatient services

No Charge

50% coinsurance

If you are pregnant

Prenatal and postnatal care

No Charge

50% coinsurance

–none—

Delivery and all inpatient services

No Charge

50% coinsurance

If you need help
recovering or have other special health needs

Home health care

No Charge

50% coinsurance

Inpatient Services: Par, member may
be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not preauthorized one business day prior.
Non-Par, $500 penalty if not preauthorized one business day prior.

Rehabilitation services

No Charge

50% coinsurance

Habilitation services

No Charge

50% coinsurance

Skilled nursing care

No Charge

50% coinsurance

Durable medical equipment

No Charge

50% coinsurance

Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).

Hospice service

No Charge

50% coinsurance

Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.

If your child needs
dental or eye care

Eye exam

No Charge

Covered

One visit per year. Reimbursed up to
$30 out-of-network. See benefit booklet for network details.

Glasses

Covered

Covered

One pair of glasses per year. Reimbursed up to $45 out-of-network.
See benefit booklet for network details.

Dental check-up

Not Covered

Not Covered

—none—

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Abortions (Except where a pregnancy is the result of rape or incest, or for a pregnancy which, as certified by a physician, places the woman in danger of death unless an abortion is performed)
  • Acupuncture
  • Dental Care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
  • 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 (Two covered every 36 months for children or bone anchored)
  • Infertility treatment
  • Private-duty nursing (With the exception of inpatient private duty nursing)
  • Routine foot care (Only in connection with diabetes)

 

Blue Choice Preferred Bronze PPO 107 – One $0 PCP Visit

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Individual:
Participating $6,800
Non-Participating $15,000
Family:
Participating $13,700
Non-Participating $45,000
Doesn’t apply to preventive care
& certain copayments.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 or other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. Individual:
Participating $6,850
Non-Participating Unlimited
Family:
Participating $13,700
Non-Participating Unlimited

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

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.

Does this plan use a network of providers?

Yes. See http://www.bcbsil.com or call 1-800-538-8833 for a list of Participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Common Medical Event

Services You May Need

Your cost if you use
a Participating
Provider

Your cost if you use
a Non-Participating
Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

20% coinsurance

50% coinsurance

First visit is no charge. No benefits will be provided for services which are not, in the reasonable judgment of Blue Cross and
Blue Shield, medically necessary

Specialist visit

20% coinsurance

50% coinsurance

—none—

Other practitioner office visit

20% coinsurance

50% coinsurance

Acupuncture not covered. Chiropractic and Osteopathic Manipulation are limited to 25 visits per calendar year.

Preventive care/screening/immunization

$80 copayment/visit

50% coinsurance

—none—

If you have a test

Diagnostic test (x-ray, blood work)

$700 copayment/visit 50% coinsurance plus 20% coinsurance

50% coinsurance

—none—

Imaging (CT / PET scans, MRIs)

No Charge

50% coinsurance

—none—

If you need drugs to
treat your illness or
condition

More information about
prescription drug coverage is available here.

Formulary generic drugs

$12/$17 copayment/
prescription
$36 Home Delivery

$17 copayment/
prescription

Lower coinsurance applies at preferred
Participating pharmacies. Retail covers a 30 day supply and home delivery covers a 90 day supply. Certain women’s preventive services will be covered with no cost to the member.
For a full list of these prescriptions and/or services, please contact
Customer Service. Non-Participating home delivery is not covered.
Non-Participating specialty drug coverage is limited to certain medications that are clarified in the prescription drug rider. For Non-Participating drug provider, you are responsible for 50% of the eligible amount after the coinsurance. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Generic drugs are not subject to the deductible.

Non-formulary generic drugs

20% coinsurance/ 25% coinsurance

25% coinsurance

Formulary brand drugs

30% coinsurance/ 40% coinsurance

40% coinsurance

Non-formulary brand drugs

40% coinsurance/ 50% coinsurance

50% coinsurance

Specialty drugs

50% coinsurance

50% coinsurance

If you have outpatient
surgery

Facility fee (e.g., ambulatory surgery center)

$400 copayment/visit
plus 20% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Abortions not covered, except where a pregnancy is the result of rape or incest, or for a pregnancy which, as
Certified by a physician, places the woman in danger of death unless an abortion is performed.

Physician/surgeon fees

20% coinsurance

50% coinsurance

If you need immediate
medical attention

Emergency room services

$1,000 copayment/
visit plus 20%
coinsurance

$1,000 copayment/
visit plus 20%
coinsurance

Copayment waived if admitted.

Emergency medical transportation

20% coinsurance

20% coinsurance

Ground and air transportation covered.

Urgent care

$75 copayment/visit

50% coinsurance

—none—

If you have a hospital
stay

Facility fee (e.g., hospital room)

$750 copayment/visit
plus 20% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Inpatient Services: Participating (Par),
member may be balance billed if preauthorization not received within
15 days prior. Non-Participating (Non-Par), $500 penalty if not preauthorized 2 business days prior.

Physician/surgeon fee

20% coinsurance

50% coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs

Mental/Behavioral health outpatient services

No Charge/office
visits or 20%
coinsurance

50% coinsurance

Pre-authorization is required for Psychological testing; Neuropsychological testing;
Electroconvulsive therapy; Repetitive Transcranial magnetic Stimulation; and Intensive Outpatient Treatment.
Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior.
Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will
be responsible for the first $1,000 or
50%, whichever is less, if not preauthorized one business day prior. Non-Par, $500 penalty if not preauthorized one business day prior.

Mental/Behavioral health inpatient services

$750 copayment/visit
plus 20% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Substance use disorder outpatient services

No Charge/office visits or 20% coinsurance

50% coinsurance

Substance use disorder inpatient services

$750 copayment/visit
plus 20% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant

Prenatal and postnatal care

20% coinsurance

50% coinsurance

–none—

Delivery and all inpatient services

$750 copayment/visit
plus 20% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you need help
recovering or have other special health needs

Home health care

20% coinsurance

50% coinsurance

Inpatient Services: Par, member may
be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not preauthorized one business day prior.
Non-Par, $500 penalty if not preauthorized one business day prior.

Rehabilitation services

20% coinsurance

50% coinsurance

Habilitation services

20% coinsurance

50% coinsurance

Skilled nursing care

20% coinsurance

50% coinsurance

Durable medical equipment

20% coinsurance

50% coinsurance

Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).

Hospice service

20% coinsurance

50% coinsurance

Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.

If your child needs
dental or eye care

Eye exam

No Charge

Covered

One visit per year. Reimbursed up to
$30 out-of-network. See benefit booklet for network details.

Glasses

Covered

Covered

One pair of glasses per year. Reimbursed up to $45 out-of-network.
See benefit booklet for network details.

Dental check-up

Not Covered

Not Covered

—none—

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Abortions (Except where a pregnancy is the result of rape or incest, or for a pregnancy which, as certified by a physician, places the woman in danger of death unless an abortion is performed)
  • Acupuncture
  • Dental Care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
  • 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 (Two covered every 36 months for children or bone anchored)
  • Infertility treatment
  • Private-duty nursing (With the exception of inpatient private duty nursing)
  • Routine foot care (Only in connection with diabetes)