Blue Precision HMO Plans


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Blue Precision HMO Plans

Our Rating: Blue Precision HMO Plans

All Blue Precision HMO Plans offer the same set of essential health benefits, quality and amount of care. The Blue Precision Gold HMO Plans are the most expensive plans, but also have the most comprehensive benefits. Gold Plans have a higher monthly premium and often lower out-of-pocket costs than Silver and Bronze plans. BCBSIL Blue Precision HMO Plans cover 100% of costs, while you only cover the copays for medical services in most cases. There are deductibles for this plan, and this is an HMO plan (when applicable for major services). You must select a Blue Precision HMO Network Primary Care Physician (PCP) when enrolling in this plan.

Blue Precision Gold HMO 207 Plan features:
  • $750 single/$2,250 family deductible and 30% coinsurance
  • $20 doctor visit / $40 specialist copayment
  • $40 urgent care copayment
  • 10% charge for Tier 1 formulary generic drugs
Blue Precision Silver HMO 206 Plan features:
  • $3,000 single/$9,000 family deductible
  • $30 doctor visit / $75 specialist copayment
  • $75 urgent care copayment
  • No charge for Tier 1 formulary generic drugs
Blue Precision Silver HMO 306 Plan features:
  • $3,300 single/$9,900 family deductible
  • $20 doctor visit / $20 specialist copayment
  • $20 urgent care copayment
  • No charge for Tier 1 formulary generic drugs
Blue Precision Bronze HMO 205 Plan features:
  • $7,400 single/$17,100 family deductible
  • $60 doctor visit / $85 specialist copayment
  • $85 urgent care copayment
  • 10% charge for Tier 1 formulary generic drugs
HMO Network

The Blue Precision HMO Plans use the Blue Precision HMO network, one the largest HMO networks in Illinois. You must select a network primary care physician (PCP), who coordinates your care within the network and referrals are required from your PCP to see a specialists.

Key Blue Precision HMO® Plan features include:
  • Lower out-of-pocket costs than PPO plans
  • You must select a network primary care physician (PCP), who coordinates your care within the network
  • Referral required to see a specialist
  • $20 doctor visit / $40 specialist copayment for Gold HMO Plan 207
  • Prescription drug coverage
  • Maternity Coverage
  • Well-adult care
  • Well-child care
  • Diagnostic testing
  • Hospital services
  • Optional dental coverage
Blue Precision HMO® Plans may be right for you if you are an individual or family who:
  • Are willing to have a primary care physician (PCP) coordinate your care
  • Prefers fixed doctor visit copayments
  • Are expecting to have surgery or major services in the near future and want the lowest out of pocket costs
  • Requires regular prescription medication

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

Blue Precision HMO Plans

Blue Precision Bronze HMO 205

Important Questions Answers Why this Matters:
What is the overall deductible?Individual: Participating $7,400
Family: Participating $17,100
Doesn’t apply to preventive care & certain copayments.
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 deductible..This plan covers some items and services even if you haven’t yet met the deductible amount. But a
copay mentor 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?
No.You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?Individual: Participating $8,550
Family: Participating $17,100
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?
Yes.This plan will pay some or all of the costs to see a specialist for covered services but only if you have a
referral before you see the specialist.
Common Medical EventServices 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 clinicPrimary care visit to treat an injury or illness

$60/visit; deductible does not apply

Not Covered

None
Specialist visit

$85/visit; deductible does not apply

Not Covered

Referral Required.
Preventive care/screening/immunization

No Charge; deductible does not apply

Not Covered

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)

$100/lab, $150/X-Ray;
deductible does not apply

Not Covered

Referral Required.
Imaging (CT / PET scans, MRIs)

$300/test; deductible does not apply

Not Covered

Referral Required.
If you need drugs to treat
your illness or condition
More information about
prescription drug
coverage is available at
www.bcbsil.com/rx21h
Preferred generic drugs

10% coinsurance

N/ALimited 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. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details.
Non-preferred generic drugs

15% coinsurance

N/A
Preferred brand drugs

20% coinsurance

N/A

Non-preferred brand drugs

30% coinsurance

N/A

Preferred Specialty drugs

40% coinsurance

N/A

Non-preferred specialty drugs

50% coinsurance

N/A

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

$300/visit plus 50%
coinsurance.

Not Covered

Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details.

 

Physician/surgeon fees

$150/visit; deductible does not apply

Not Covered

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

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

$850/day; deductible does not apply

Not Covered

Referral required.
Physician/surgeon fee

No Charge; deductible does not apply

Not Covered

If you need mental
health, behavioral health,
or substance abuse
services
Outpatient services

$60/office visits; deductible does not apply 50% coinsurance for other outpatient services

$60/office visits; deductible does not apply 50% coinsurance for other
outpatient services

Telepsychiatry benefits are available; see your
benefit booklet* for details.
Inpatient services

$850/day; deductible does
not apply

$850/day; deductible does
not apply

None
If you are pregnantOffice visits

Primary Care: $60
Specialist: $85; deductible
does not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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

No Charge; deductible does
not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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/day; deductible does
not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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

No Charge; deductible does not apply

Not Covered

Referral required.
Rehabilitation services

$70 /visit; deductible does not apply

Not Covered

Habilitation services

$70/visit; deductible does not apply

Not Covered

Skilled nursing care

$500/day; deductible does not apply

Not Covered

Durable medical equipment

No Charge; deductible does not apply

Not Covered

Referral required.
Hospice service50% coinsurance

Not Covered

Referral required.
If your child needs
dental or eye care
Children’s eye exam

No Charge; deductible does not apply

Not Covered

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

No Charge; deductible does not apply

Not Covered

One pair of glasses up to age 19 per year. See
your benefit booklet* 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.
  • 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 ofcongenital deformities or conditions resulting fromaccidental 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 eye care (Adult, 1 visit per benefit period)
  • Routine foot care (only in connection with diabetes)

Blue Precision HMO Plans

Blue Precision Gold HMO 207

 

Important Questions Answers Why this Matters:
What is the overall deductible?Individual:
Participating $750
Family:
Participating $2,250
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 deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a
copay mentor 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?No.You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
Individual:
Participating $8,550
Family:
Participating $17,100
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.comor 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 I need a referral to see a specialist?Yes.This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.
Common Medical EventServices 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 clinicPrimary care visit to treat an injury or illness

$20/visit; deductible does not apply

Not Covered

None
Specialist visit

$40/visit; deductible does not apply

Not Covered

Referral Required.
Preventive care/screening/immunization

No Charge; deductible does
not apply

Not Covered

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)

$40/test; deductible does not apply

Not Covered

Referral Required.
Imaging (CT / PET scans, MRIs)

$250/test; deductible does
not apply

Not Covered

Referral Required.
If you need drugs to
treat your illness or
condition         More information about
prescription drug coverage is available here.
Preferred generic drugs

10% coinsurance

Not CoveredLimited 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. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details.
Non-preferred generic drugs

15% coinsurance

Not Covered
Preferred brand drugs

20% coinsurance

Not Covered

Non-preferred brand drugs

30% coinsurance

Not Covered

Preferred specialty drugs

40% coinsurance

Not Covered

Non-preferred specialty drugs

50% coinsurance

Not Covered

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

$300/visit plus 30%
coinsurance

Not Covered

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

$40/visit; deductible does not apply

Not Covered

If you need immediate
medical attention
Emergency room services

$1,000 copayment/
visit plus 30%
coinsurance

$1,000 copayment/
visit plus 30%
coinsurance

Per occurrence copayment waived upon inpatient admission.
Emergency medical transportation

30% coinsurance

30% coinsurance

None
Urgent care

$40/visit; deductible does not
apply

Not Covered

Must be affiliated with member’s chosen medical group or referral required.
If you have a hospital
stay
Facility fee (e.g., hospital room)

$750/day; deductible does
not apply

Not Covered

Referral required.
Physician/surgeon fee

No Charge, deductible does not apply

Not Covered

If you need mental
health, behavioral health,
or substance abuse
services
Mental/Behavioral health outpatient services

$20/office visits; deductible
does not apply
30% coinsurance for other
outpatient services

$20/office visits; deductible
does not apply
30% coinsurance for other
outpatient services

Telepsychiatry benefits are available; see your benefit booklet* for details.
Mental/Behavioral health inpatient services

$750/day; deductible does
not apply

$750/day; deductible does
not apply

None
If you are pregnantOffice visits

Primary Care: $20
Specialist: $40; deductible
does not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for
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

$750/day; deductible does
not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for
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

No Charge, deductible does
not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for
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

No Charge; deductible does
not apply

Not Covered

Referral required.
Rehabilitation services

$40 /visit; deductible does
not apply

Not Covered

Habilitation services

$40/visit; deductible does not
apply

Not Covered

Skilled nursing care

$500/day; deductible does
not apply

Not Covered

Durable medical equipment

No Charge; deductible does not apply

Not Covered

Referral required.
Hospice service30% coinsurance

Not Covered

Referral required.
If your child needs
dental or eye care
Eye exam

No Charge; deductible does
not apply

Not Covered

One visit per year. See your benefit booklet* for details.
Glasses

No Charge; deductible does
not apply

Not Covered

One pair of glasses up to age 19 per year. See your benefit booklet* for 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.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • 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.)
  • 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 eye care (Adult, 1 visit per benefit period)
  • Routine foot care (only in connection with diabetes)

Blue Precision HMO Plans

Blue Precision Silver HMO 206

Important Questions Answers Why this Matters:
What is the overall deductible?Individual: Participating $3,000
Family: Participating $9,000
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 deductible.This 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
Family: Participating $17,100
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?
Yes.This plan will pay some or all of the costs to see a specialist for covered services but only if you have a
referral before you see the specialist.
Common Medical EventServices 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 clinicPrimary care visit to treat an injury or illness

$30/visit; deductible does not apply

Not Covered

None
Specialist visit

$75/visit; deductible does not apply

Not Covered

Referral Required.
Preventive care/screening/immunization

No Charge; deductible does not apply

Not Covered

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)

$20/test; deductible does not apply

Not Covered

Referral Required.
Imaging (CT / PET scans, MRIs)

$350/test; deductible does not apply

Not Covered

Referral Required.
If you need drugs to treat
your illness or condition
More information about
prescription drug
coverage is available at
www.bcbsil.com/rx21h
Preferred generic drugs

No Charge after deductible

N/ALimited 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. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details

Non-preferred generic drugs

10% coinsurance

N/A
Preferred brand drugs

20% coinsurance

N/A

Non-preferred brand drugs

30% coinsurance

N/A

Preferred specialty drugs

40% coinsurance

N/A

Non-preferred specialty drugs

50% coinsurance

N/A

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

50% coinsurance

Not Covered

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

$30/visit; deductible does not apply

Not Covered

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

None
Urgent care

$75/visit; deductible does not apply

Not Covered

Must be affiliated with member’s chosen medical group or referral required.
If you have a hospital
stay
Facility fee (e.g., hospital room)

$500/visit plus 50%
coinsurance

Not Covered

Referral required.
Physician/surgeon fee

No Charge; deductible does
not apply

Not Covered

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

$30/office visits; deductible
does not apply
50% coinsurance for other
outpatient services

$30/office visits; deductible
does not apply
50% coinsurance for other
outpatient services

Telepsychiatry benefits are available; see your benefit booklet* for details.
Inpatient services

$500/visit plus 50%
coinsurance

$500/visit plus 50%
coinsurance

None
If you are pregnantOffice visits

Primary Care: $30
Specialist: $75; deductible
does not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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

No Charge deductible does not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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

$500/visit plus 50%
coinsurance

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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

No Charge; deductible does not apply

Not Covered

Referral required.
Rehabilitation services

$30 /visit; deductible does not apply

Not Covered

Habilitation services$30/visit; deductible does not apply

Not Covered

Skilled nursing care

50% coinsurance

Not Covered

Durable medical equipment

No Charge; deductible does not apply

Not Covered

Referral required.
Hospice service50% coinsurance

Not Covered

Referral required.
If your child needs
dental or eye care
Children’s eye exam

No Charge; deductible does not apply

Not Covered

One visit per year. See your benefit booklet* for details.
Children’s glasses

No Charge; deductible does not apply

Not Covered

One pair of glasses up to age 19 per year. See your benefit booklet* for details.
Children’s dental check-up

Not Covered

Not Covered

None

 

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.
  • 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.)
  • 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 eye care (Adult, 1 visit per benefit period)
  • Routine foot care (only in connection with diabetes)

Blue Precision HMO Plans

Blue Precision Silver HMO 306

Important Questions Answers Why this Matters:
What is the overall deductible?Individual: Participating $3,300
Family: Participating $9,900
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 deductible.This 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
Family: Participating $17,100
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?
Yes.This plan will pay some or all of the costs to see a specialist for covered services but only if you have a
referral before you see the specialist.
Common Medical EventServices 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 clinicPrimary care visit to treat an injury or illness

$20/visit; deductible does not apply

Not Covered

None
Specialist visit

$20/visit; deductible does not apply

Not Covered

Referral Required.
Preventive care/screening/immunization

No Charge; deductible does not apply

Not Covered

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)

$35/test; deductible does not apply

Not Covered

Referral Required.
Imaging (CT / PET scans, MRIs)

$250/test; deductible does not apply

Not Covered

Referral Required.
If you need drugs to treat
your illness or condition
More information about
prescription drug
coverage is available at
www.bcbsil.com/rx21h
Preferred generic drugs

Retail – $10/prescription
Mail – $30/prescription;
deductible does not apply

N/ALimited 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. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details

Non-preferred generic drugs

Retail – $20/prescription
Mail – $60/prescription;
deductible does not apply

N/A
Preferred brand drugs

30% coinsurance

N/A

Non-preferred brand drugs

40% coinsurance

N/A

Preferred specialty drugs

45% coinsurance

N/A

Non-preferred specialty drugs

50% coinsurance

N/A

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

$600/visit plus 50%
coinsurance

Not Covered

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

$200/visit; deductible does
not apply

Not Covered

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

None
Urgent care

$20/visit; deductible does not apply

Not Covered

Must be affiliated with member’s chosen medical group or referral required.
If you have a hospital
stay
Facility fee (e.g., hospital room)

$850/visit plus 50%
coinsurance

Not Covered

Referral required.
Physician/surgeon fee

No Charge; deductible does
not apply

Not Covered

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

$20/office visits; deductible
does not apply
30% coinsurance for other
outpatient services

$20/office visits; deductible
does not apply
30% coinsurance for other
outpatient services

Telepsychiatry benefits are available; see your benefit booklet* for details.
Inpatient services

$850/visit plus 50%
coinsurance

$850/visit plus 50%
coinsurance

None
If you are pregnantOffice visits

Primary Care: $20
Specialist: $20; deductible
does not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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

No Charge deductible does not apply

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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

Not Covered

Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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

No Charge; deductible does not apply

Not Covered

Referral required.
Rehabilitation services

$30 /visit; deductible does not apply

Not Covered

Habilitation services$30/visit; deductible does not apply

Not Covered

Skilled nursing care

50% coinsurance

Not Covered

Durable medical equipment

No Charge; deductible does not apply

Not Covered

Referral required.
Hospice service50% coinsurance

Not Covered

Referral required.
If your child needs
dental or eye care
Children’s eye exam

No Charge; deductible does not apply

Not Covered

One visit per year. See your benefit booklet* for details.
Children’s glasses

No Charge; deductible does not apply

Not Covered

One pair of glasses up to age 19 per year. See your benefit booklet* 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.
  • 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.)
  • 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 eye care (Adult, 1 visit per benefit period)
  • Routine foot care (only in connection with diabetes)