Blue Choice Preferred Silver PPO


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Blue Choice Preferred Silver PPO Plans

Our Rating:

Blue Choice Preferred Silver 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 and the largest PPO network BCBSIL offers to individual health lans. 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.

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 Silver PPO Plans have a higher monthly premium and often lower out-of-pocket costs than Blue Choice Preferred Silver plans.

There are 3 Blue Choice Preferred Silver PPO Plans:
Blue Choice Preferred PPO Network

The Blue Choice Preferred PPO Silver 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 Silver PPO® plan features include:
Blue Choice Preferred Silver 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 fixed doctor visit copayments
  • Regularly visits a doctor
  • Requires regular prescription medication

Compare the features, options and costs of Blue Choice Preferred Silver® PPO 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 Gold PPO 204

 

Important Questions Answers Why this Matters:
What is the overall deductible? Individual:
Participating $750
Non-Participating $15,000
Family:
Participating $2,250
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 $7,350
Non-Participating Unlimited
Family:
Participating $14,700
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

$15 copay

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

$50 copay

50% coinsurance

—none—
Other practitioner office visit

50% 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)

Hospital – 30% coinsurance

Non-Hospital – 20% coinsurance

50% coinsurance

—none—
Imaging (CT / PET scans, MRIs)

Hospital – 50% coinsurance

Non-Hospital – 30% coinsurance

50% coinsurance

—none—
If you need drugs to
treat your illness or
condition. More information about
prescription drug coverage is available here.
Preferred generic drugs

No copayment/
prescription
$0 Home Delivery

$10 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-preferred generic drugs

$10 copayment/
prescription
$30 Home Delivery

$20 copayment/
prescription

Preferred brand drugs

Preferred – 20% coinsurance/
Non-Preferred – 30%
coinsurance

30% coinsurance

Non-preferred brand drugs Preferred – 35% coinsurance/
Non-Preferred – 40%
coinsurance

40% coinsurance

Preferred Specialty drugs 45% coinsurance 45% coinsurance
Non-Preferred Specialty drugs 45% coinsurance 45% coinsurance
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center) Hospital – 30% coinsurance

Non-Hospital – 20% coinsurance

$1,500/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 $1,000/visit plus 30% coinsurance $1,000/visit plus 23% coinsurance Copayment waived if admitted.
Emergency medical transportation

30% coinsurance

30% coinsurance

Ground and air transportation covered.
Urgent care

$50 copay/visit

50% coinsurance

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

$850/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

$200/visit plus 20% coinsurance

50% coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health outpatient services $15/visit or 30% coinsurance for other outpatient services

50% coinsurance

Copayment may apply. Pre-authorization is required for Psychological testing; Neuropsychological testing; Electroconvulsive therapy; Repetitive Transcranial magnetic Stimulation; Autism Spectrum Disorder; 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

$850/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

$850/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant Office visits

$15 PCP/$50 Specialist

50% coinsurance

Copayment applies to first prenatal
visit per pregnancy. Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (ie. ultrasound). Inpatient copay is charged in addition to the overall deductible. Service provided at no charge with CHS referral.
Childbirth/delivery professional services

50% coinsurance

50% coinsurance

Childbirth/delivery facility services

$850/visit
plus 50% coinsurance

$1,500/visit plus 50%
coinsurance

If you need help
recovering or have other special health needs
Home health care

30% coinsurance

30% coinsurance

Preauthorization required. Failure to preauthorize may result in claim denial.
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
Children’s Eye exam

No Charge

Not Covered

One visit per year.  See benefit booklet for network details.
Children’s Glasses

No Charge

Not Covered

One pair of glasses per year.
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 (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 Silver PPO 102

Important Questions Answers Why this Matters:
What is the overall deductible? Individual:
Participating $3,000
Non-Participating $15,000
Family:
Participating $7,150
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 $7,150
Non-Participating Unlimited
Family:
Participating $14,300
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 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

$60 copayment/visit

50% coinsurance

—none—
Other practitioner office visit

$60 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
conditionMore 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) $300 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 $600 copayment/visit
plus 30% coinsurance
$600 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)

$500 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

Copayment may apply. 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

$500 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

$500 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant Prenatal and postnatal care

$40 copayment/visit

50% coinsurance

Copyament applies to first prenatal
visit per pregnancy.
Delivery and all inpatient services

$500 copayment/visit
plus 30% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

–none—
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 Silver PPO 203

 

Important Questions Answers Why this Matters:
What is the overall deductible? Individual:
Participating $1,450
Non-Participating $15,000
Family:
Participating $4,350
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 $7,350
Non-Participating Unlimited
Family:
Participating $14,700
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

$10 copay

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

50% coinsurance

50% coinsurance

—none—
Other practitioner office visit

50% 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)

Hospital – 50% coinsurance

Non-Hospital – 30% coinsurance

50% coinsurance

—none—
Imaging (CT / PET scans, MRIs)

Hospital – 50% coinsurance

Non-Hospital – 30% coinsurance

50% coinsurance

—none—
If you need drugs to
treat your illness or
conditionMore information about
prescription drug coverage is available here.
Preferred generic drugs

$5/$10 copayment/
prescription
$15 Home Delivery

$15 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-preferred generic drugs

$15/$25 copayment/
prescription
$45 Home Delivery

$25 copayment/
prescription

Preferred brand drugs

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

35% coinsurance

Non-preferred brand drugs Preferred – 35% coinsurance/
Non-Preferred – 35%
coinsurance

40% coinsurance

Preferred Specialty drugs

40% coinsurance

45% coinsurance

Non-Preferred Specialty drugs

50% coinsurance

50% coinsurance

If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center) Hospital – $600/visit
plus 50% coinsuranceNon-Hospital – $600/visit plus 30% coinsurance
$1,500/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

$200/visit plus 50% coinsurance

50% coinsurance

If you need immediate
medical attention
Emergency room services $1,000/visit plus 50% coinsurance $1,000/visit plus 20% coinsurance Copayment waived if admitted.
Emergency medical transportation

50% coinsurance

50% coinsurance

Ground and air transportation covered.
Urgent care

$15 copayment/visit

50% coinsurance

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

$850/visit
plus 50% 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

$200/visit plus 20% coinsurance

50% coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health outpatient services 50% coinsurance

50% coinsurance

Copayment may apply. 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

$850/visit
plus 50% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Substance use disorder outpatient services

50% coinsurance

50% coinsurance

Substance use disorder inpatient services

$850/visit
plus 50% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant Childbirth/delivery professional services

50% coinsurance

50% coinsurance

Copyament applies to first prenatal
visit per pregnancy.
Childbirth/delivery facility services

$850/visit
plus 50% coinsurance

$1,500/visit plus 50%
coinsurance

–none—
If you need help
recovering or have other special health needs
Home health care

50% 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

50% coinsurance

50% coinsurance

Habilitation services

50% coinsurance

50% coinsurance

Skilled nursing care

50% coinsurance

50% coinsurance

Durable medical equipment

50% 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

50% 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
Children’s Eye exam

No Charge

Not Covered

One visit per year.  See benefit booklet for network details.
Children’s Glasses

No Charge

Not Covered

One pair of glasses per year.
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)