Blue Cross BlueShield of Illinois
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Blue Choice Bronze Plan 005 - Plan Benefits


Blue Choice PPO Bronze Plan 005

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Benefit HighlightBlue Choice Bronze 005
Plan Features
Lifetime Maximum Unlimited
Participating providers BlueChoice PPO Network
Smaller PPO Network
Individual Deductible $5,000
Family Deductible $12,700
Coinsurance 80%
Out of Pocket Maximum
Includes deductible
$6,250
Family Out of Pocket Maximum
Includes deductible
$12,700
Office Visit Copay (Primary Care/Specialist) No copay, you pay 80% after deductible unless preventive care
Medical Coverage Details
Outpatient Surgery 80% after deductible
Inpatient Hospital Medical / Surgical Services
Hospital Services and Hospital Diagnostic Testing
80% after deductible
Emergency Room / Outpatient Emergency Care
Physician and Hospital
80% after deductible
Outpatient Hospital Diagnostic Testing 80% after deductible
Mental Illness & Substance Abuse Rehab
(Outpatient Hospital/ Physcian Care)
80% after deductible
Mental Illness & Substance Abuse Treatment
(Inpatient Hospital Care)
80% after deductible
Mental Illness & Substance Abuse Treatment
(Inpatient Physician Care)
80% coinsurance after deductible
Preventive Care Covered at 100%, no copay
Maternity Coverage 80% after deductible
Prescription Drugs
Preferred Generics 80% after deductible
Non Preferred Generics 80% after deductible
Preferred Formulary 80% after deductible
Non-Preferred Formulary 80% after deductible
Specialty 80% after deductible
Prescription Drug Formulary Standard
Cost Reductions
Tax Credit Eligible Yes
Cost Sharing Eligible No
HSA Eligibile Yes
Outline of Coverage PDF icon