BlueCare Direct with Advocate


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BLUECARE DIRECTSM

Blue Care Direct HMO

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Chicago-area residents now have a new choice for health care coverage. Blue Cross and Blue Shield of Illinois (BCBSIL) has teamed up with Advocate Health Care* to offer a new, more affordable health plan — BlueCare Direct.

BlueCare Direct. Great Access. More Affordable Coverage.

BlueCare Direct combines the strength, expertise and reputation of two of the state’s most respected leaders in the health industry. Advocate is the largest health system in Illinois, and BCBSIL is the largest health insurer in the state. Advocate is uniquely positioned to deliver quality patient outcomes, while working to manage overall health care costs, with the goal of delivering value to our members.

BlueCare Direct provides access to Advocate Health Care’s vast network of doctors and hospitals in Cook, DuPage, Kane, Lake and Will counties. It’s being offered to our individual, family and small group customers on our website. Along with all the features of an HMO, BlueCare Direct offers:

  • Lower monthly premiums and lower out-of-pocket costs than most other HMO plans available to individual plan members
  • Same-day appointments for primary care**
  • Self-refer to specialists within the Advocate network without a PCP referral (except in some instances such as for surgical procedures or physical therapy regimens)
  • Same day mammograms, and get the results on the same day**
  • See a cardiologist within 24 hours
  • Access to Advocate’s network of over 250 sites of care, including:
    • 4,000+ Advocate doctors
    • 11 Advocate community hospitals
    • The state’s largest integrated children’s network
    • The state’s largest home health and hospice companies
    • One of the region’s largest medical groups

BlueCare DirectSM is a unique product that combines the strength, expertise and reputation of two of the state’s leading health organizations. It provides health care coverage that gives members access to the resources of the largest health care system in Illinois, including:

Advocate Direct Hospital Network

  • More than 4,000 Advocate primary care and specialty physicians across Cook, DuPage, Lake, Kane and Will counties
  • 10 Advocate hospitals, including Advocate Children’s Hospital with campuses in Park Ridge and Oak Lawn
  • Advocate Good Shepherd in Barrington
  • Advocate Illinois Masonic Medical Center in Chicago
  • Advocate Trinity Hospital in Chicago
  • Advocate Good Samaritan Hospital in Downers Grove
  • Advocate Sherman Hospital in Elgin
  • Advocate South Suburban in Hazel Crest
  • Advocate Condell Medical Center in Libertyville
  • Advocate Christ Hospital Medical Center and Advocate Children’s Hospital in Oak Lawn
  • Advocate General Hospital and Advocate Lutheran General Children’s Hospital in Park Ridge
  • Advocate’s home health and hospice agency for transition from hospital to home

Because of its Advocate-exclusive network, BlueCare

BlueCare Direct is ideal for your customers who live and work in the greater Chicago area and have no need to pay more for a network that includes providers in other parts of the state.

 

BlueCare Direct Gold 101 with Advocate

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Individual:
Participating $1,750
Family:
Participating $5,250
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 $3,500
Family:
Participating $10,500

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?

Yes. All specialist visits require a
written PCP referral unless it’s for
an OB/GYN or for emergency care.

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.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. 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

$25 copayment/visit

Not Covered

Services or supplies that are not ordered by your Primary Care. Physician or Women’s Principal Health Care Provider, except
emergency and routine vision exams, are not covered.

Specialist visit

$50 copayment/visit

Not Covered

Referral Required.

Other practitioner office visit

$50 copayment/visit

Not Covered

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

Preventive care/screening/immunization

No Charge

Not Covered

—none—

If you have a test

Diagnostic test (x-ray, blood work)

$50 copayment/visit

Not Covered

Referral Required.

Imaging (CT / PET scans, MRIs)

$250 copayment/visit

Not Covered

Referral Required.

If you need drugs to
treat your illness or
condition

More information about
prescription drug coverage is available here.

Formulary generic drugs

No Charge

Not Covered

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.

Non-formulary generic drugs

20% coinsurance

Not Covered

Formulary brand drugs

20% coinsurance

Not Covered

Non-formulary brand drugs

30% coinsurance

Not Covered

Specialty drugs

40% coinsurance

Not Covered

If you have outpatient
surgery

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

$200 copayment/visit Not Covered
plus 20% coinsurance

Not Covered

Referral required. 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

$50 copayment/visit

Not Covered

If you need immediate
medical attention

Emergency room services

$600 copayment/
visit plus 20%
coinsurance

$600 copayment/
visit plus 20%
coinsurance

Copayment waived if admitted.

Emergency medical transportation

20% coinsurance

20% coinsurance

Ground and air transportation covered.

Urgent care

$25 copayment/visit

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)

$400 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

Physician/surgeon fee

No Charge

Not Covered

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

Mental/Behavioral health outpatient services

$25  copayment/visit Not Covered
or 20% coinsurance

Not Covered

Referral required.

Mental/Behavioral health inpatient services

$400 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

Substance use disorder outpatient services

$25 copayment/visit
or 20% coinsurance

Not Covered

Referral required.

Substance use disorder inpatient services

$400 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

If you are pregnant

Prenatal and postnatal care

$25 copayment

Not Covered

Copyament applies to first prenatal visit per pregnancy.

Delivery and all inpatient services

$400 copayment/day

Not Covered

Referral required. Copayment applies per day until the Out-of-Pocket limit has been met.

If you need help
recovering or have other special health needs

Home health care

20% coinsurance

Not Covered

Referral required.

Rehabilitation services

$50 copayment/visit

Not Covered

Habilitation services

$50 copayment/visit

Not Covered

Skilled nursing care

20% coinsurance

Not Covered

Durable medical equipment

20% coinsurance

Not Covered

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

Not Covered

Referral required.

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)

 

BlueCare Direct Silver 102 with Advocate

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Individual:
Participating $2,600
Family:
Participating $6,000
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
Family:
Participating $14,300

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?

Yes. All specialist visits require a
written PCP referral unless it’s for
an OB/GYN or for emergency care.

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.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. 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

$30 copayment/visit

Not Covered

Services or supplies that are not ordered by your Primary Care. Physician or Women’s Principal Health Care Provider, except
emergency and routine vision exams, are not covered.

Specialist visit

$50 copayment/visit

Not Covered

Referral Required.

Other practitioner office visit

$50 copayment/visit

Not Covered

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

Preventive care/screening/immunization

No Charge

Not Covered

—none—

If you have a test

Diagnostic test (x-ray, blood work)

$250 copayment/visit

Not Covered

Referral Required.

Imaging (CT / PET scans, MRIs)

$750 copayment/visit

Not Covered

Referral Required.

If you need drugs to
treat your illness or
condition

More information about
prescription drug coverage is available here.

Formulary generic drugs

No Charge

Not Covered

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.

Non-formulary generic drugs

20% coinsurance

Not Covered

Formulary brand drugs

20% coinsurance

Not Covered

Non-formulary brand drugs

30% coinsurance

Not Covered

Specialty drugs

40% coinsurance

Not Covered

If you have outpatient
surgery

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

$500 copayment/visit Not Covered
plus 20% coinsurance

Not Covered

Referral required. 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

$250 copayment/visit

Not Covered

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

$30 copayment/visit

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 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

Physician/surgeon fee

No Charge

Not Covered

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

Mental/Behavioral health outpatient services

$30  copayment/visit Not Covered
or 20% coinsurance

Not Covered

Referral required.

Mental/Behavioral health inpatient services

$750 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

Substance use disorder outpatient services

$30 copayment/visit
or 20% coinsurance

Not Covered

Referral required.

Substance use disorder inpatient services

$750 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

If you are pregnant

Prenatal and postnatal care

$50 copayment

Not Covered

Copyament applies to first prenatal visit per pregnancy.

Delivery and all inpatient services

$750 copayment/day

Not Covered

Referral required. Copayment applies per day until the Out-of-Pocket limit has been met.

If you need help
recovering or have other special health needs

Home health care

20% coinsurance

Not Covered

Referral required.

Rehabilitation services

$250 copayment/visit

Not Covered

Habilitation services

$250 copayment/visit

Not Covered

Skilled nursing care

20% coinsurance

Not Covered

Durable medical equipment

20% coinsurance

Not Covered

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

Not Covered

Referral required.

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)

BlueCare Direct Bronze 103 with Advocate

Important Questions

Answers

Why this Matters:

What is the overall deductible?

Individual:
Participating $6,000
Family:
Participating $13,700
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
Family:
Participating $13,700

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?

Yes. All specialist visits require a
written PCP referral unless it’s for
an OB/GYN or for emergency care.

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.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. 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

$50 copayment/visit

Not Covered

Services or supplies that are not ordered by your Primary Care. Physician or Women’s Principal Health Care Provider, except
emergency and routine vision exams, are not covered.

Specialist visit

$100 copayment/visit

Not Covered

Referral Required.

Other practitioner office visit

$100 copayment/visit

Not Covered

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

Preventive care/screening/immunization

No Charge

Not Covered

—none—

If you have a test

Diagnostic test (x-ray, blood work)

$250 copayment/visit

Not Covered

Referral Required.

Imaging (CT / PET scans, MRIs)

$750 copayment/visit

Not Covered

Referral Required.

If you need drugs to
treat your illness or
condition

More information about
prescription drug coverage is available here.

Formulary generic drugs

No Charge

Not Covered

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.

Non-formulary generic drugs

20% coinsurance

Not Covered

Formulary brand drugs

20% coinsurance

Not Covered

Non-formulary brand drugs

30% coinsurance

Not Covered

Specialty drugs

40% coinsurance

Not Covered

If you have outpatient
surgery

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

$500 copayment/visit Not Covered
plus 50% coinsurance

Not Covered

Referral required. 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

$250 copayment/visit

Not Covered

If you need immediate
medical attention

Emergency room services

$1,000 copayment/
visit plus 50%
coinsurance

$1,000 copayment/
visit plus 50%
coinsurance

Copayment waived if admitted.

Emergency medical transportation

50% coinsurance

50% coinsurance

Ground and air transportation covered.

Urgent care

$50 copayment/visit

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 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

Physician/surgeon fee

No Charge

Not Covered

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

Mental/Behavioral health outpatient services

$50  copayment/visit Not Covered
or 50% coinsurance

Not Covered

Referral required.

Mental/Behavioral health inpatient services

$750 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

Substance use disorder outpatient services

$50 copayment/visit
or 50% coinsurance

Not Covered

Referral required.

Substance use disorder inpatient services

$750 copayment/day

Not Covered

Referral required.
Copayment applies per day until the
Out-of-Pocket limit has been met.

If you are pregnant

Prenatal and postnatal care

$50 copayment

Not Covered

Copyament applies to first prenatal visit per pregnancy.

Delivery and all inpatient services

$750 copayment/day

Not Covered

Referral required. Copayment applies per day until the Out-of-Pocket limit has been met.

If you need help
recovering or have other special health needs

Home health care

50% coinsurance

Not Covered

Referral required.

Rehabilitation services

$250 copayment/visit

Not Covered

Habilitation services

$250 copayment/visit

Not Covered

Skilled nursing care

50% coinsurance

Not Covered

Durable medical equipment

50% coinsurance

Not Covered

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

Not Covered

Referral required.

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)