Blue Choice Preferred Gold Plans


Blue Cross BlueShield of Illinois
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Blue Choice Preferred Gold PPO Plans

Our Rating:

Blue Choice Preferred Gold PPO Plans offers 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 that is was discontinued beginning January 1st, 2016. If you can accept some reduced hospital and physician choices, Blue Choice Preferred Gold PPO may be a great option for you.

The differences are how much your premium costs each month, what portion of the bill you pay for things like hospital visits or prescription medications, and how much your total out-of-pocket costs are. Blue Choice Preferred Gold PPO Plans have a higher monthly premium and often lower out-of-pocket costs than Blue Choice Preferred Silver plans.

There is only 1 Blue Choice Preferred Gold PPO Plan:
Blue Choice Preferred PPO Network

The Blue Choice Preferred PPO Gold Plans use the Blue Choice Preferred PPO network, a smaller PPO network that includes about 50% of doctors and hospitals in Illinois.

Key Blue Choice Preferred Gold PPO® plan features include:
  • $20 primary care copays
  • $40 specialist copays
  • Maternity Coverage
  • Well-adult care
  • Well-child care
  • Diagnostic testing
  • Hospital services
  • Optional dental coverage
Blue Choice Preferred Gold PPO Plans may be right for you if you are an individual or family who:
  • Seeks coverage comparable to what is offered by employers
  • Prefers low, fixed doctor visit copayments
  • Regularly visits a doctor
  • Requires regular prescription medication

Compare the features, options and costs of BCBSIL Gold 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.

Add-ons and Plan Options

You can customize any Gold plan to add-on dental insurance.

Optional Dental Coverage

  • Covers cleanings, check-ups and other preventive procedures immediately – no waiting period
  • One of the highest maximum benefit amounts available – up to $1,500 per person per year
  • Up to 20% discount for orthodontic services at participating providers
  • Learn more about optional dental coverage

Blue Choice Gold Plan Costs

Health insurance costs include monthly premium payments, individual/family deductibles, out-of-pocket expenses, copayments, and coinsurance. Here is what you can expect with Blue Choice Gold® plans:

  • Individual in-network deductibles ranging from $1,000 to $3,250
  • $10 or $30 office visit copayments
  • $0 or $10 copayments for generic prescription drugs
  • Coinsurance of 100% to 80% percent of services provided in-network, after deductible and copayments are met
  • Annual out-of-pocket maximum of $3,250 and $3,500 for individuals and $9,750 or $10,500 for families, depending on the plan

By using a contracting BCBS PPO hospital, doctor or specialist you are able to save on premiums and the cost of covered services. You do not need to select a primary care physician or obtain a referral to see a specialist.

For more information on costs, get a quick quote or see the benefit summary.

Plan Renewals

Your BCBSIL policy can ONLY be terminated for the following reasons:

  • Failure to pay
  • The plan is discontinued (90 days notice given with an option to convert to any plan we offer)
  • Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)
  • If you no longer reside, live or work in an area where we are authorized to do business

Prescription Drug Coverage

For the Blue PPO Gold and Blue Choice Gold Plans, there is a prescription drug card benefit that includes a $0 or $10 copay for generic, $35 or $75 copay for formulary drugs, and a $150 copay for specialty medications. This benefit is immediately available and not subject to a deductible.

There is a also a Home Delivery prescription benefit available with these 3 deductible options where you can receive a 90 day supply in the mail for the cost of a 60 day supply and is subject to a maximum cost of $300 per prescription.

Outpatient Prescription Drug Benefit Gold Plan 001 Gold Plan 002
Preferred Generics $0 copay $0 copay
Non-Preferred Generics $10 copay $10 copay
Preferred Formulary $35 copay $35 copay
Non-Preferred Formulary $75 copay $75 copay
Specialty $150 copay $150 copay
Home Delivery
Up to a 90-day supply of maintenance drugs is available through home delivery and is subject to $300 maximum per prescription.
Preferred Generics $0 copay $0 copay
Non-Preferred Generics $20 copay $20 copay
Preferred Formulary $70 copay $70 copay
Non-Preferred Formulary $150 copay $150 copay
Specialty $300 copay $300 copay

What’s Included with Blue PPO Gold Plans®

  • Coverage for major hospital, medical and surgical expenses incurred as a result of a covered accident or sickness
  • Coverage for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care
  • Although you can go to the hospital or doctor of your choice, your benefits under a Blue Choice Gold® plan will be higher, and your costs lower, when you use the services of participating BlueChoice® PPO providers.
  • Maternity Coverage
  • As with all individual Blue Cross and Blue Shield of Illinois plans, the freedom of not having to select a primary care doctor or obtain a referral to see a specialist

More Plan Details

It’s important to know the critical features of the health plan you are considering. Each plan’s Outline of Coverage provides brief descriptions of the basic provisions the Blue Choice Gold plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

Blue Choice Preferred Gold PPO 101

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Individual:
Participating $500
Non-Participating $15,000
Family:
Participating $1,500
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 $5,250
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 copayment/visit

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

$40 copayment/visit

50% coinsurance

—none—

Other practitioner office visit

$40 copayment/visit

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)

30% coinsurance

50% coinsurance

—none—

Imaging (CT / PET scans, MRIs)

30% 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

$0/$5 copayment/
prescription
$0 Home Delivery

$5 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

$10/$15 copayment/
prescription
$30 Home Delivery

$15 copayment/
prescription

Formulary brand drugs

$50/$60 copayment/
prescription
$150 Home Delivery

$60 copayment/
prescription

Non-formulary brand drugs

$100/$110
copayment/
prescription
$300 Home Delivery

$110 copayment/
prescription

Specialty drugs

30% coinsurance

50% coinsurance

If you have outpatient
surgery

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

$200 copayment/visit
plus 30% 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

30% coinsurance

50% coinsurance

If you need immediate
medical attention

Emergency room services

$500 copayment/visit
plus 30% coinsurance

$500 copayment/visit
plus 30% coinsurance

Copayment waived if admitted.

Emergency medical transportation

30% coinsurance

30% 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)

$300 copayment/visit
plus 30% 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

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

$300 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Substance use disorder outpatient services

30% coinsurance

50% coinsurance

Substance use disorder inpatient services

$300 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant

Prenatal and postnatal care

$20 copayment/visit

50% coinsurance

–none—

Delivery and all inpatient services

$300 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 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)