Blue Choice Preferred Gold Plans


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Blue Choice Preferred Gold Plans

Blue Choice Preferred Gold PPO Plans

Our Rating: Blue Choice Preferred Gold Plans

Blue Choice Preferred Gold PPO Plans offers a respectable PPO network of doctors and hospitals and the convenience of never needing a referral to see a specialist. Blue Choice Preferred PPO Plans are coupled with the Blue Choice Preferred PPO network, a smaller version of the “standard” Blue Cross Blue Shield of Illinois PPO network that is was discontinued beginning January 1st, 2016. If you can accept some reduced hospital and physician choices, Blue Choice Preferred Gold PPO may be a great option for you.

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

 Blue Choice Preferred Gold PPO Plans:
  • Blue Choice Preferred Gold Plan 204 – $750 individual / $2,250 family deductible and 30% coinsurance
  • Blue Choice Preferred Gold Plan 707 – $2,000 individual / $4,000 family deductible and 25% coinsurance
Blue Choice Preferred PPO Network

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

Blue Choice Preferred Gold PPO Plans may be right for you if you are an individual or family who:
  • Seeks coverage comparable to what is offered by employers
  • Prefers low, fixed doctor visit copayments
  • Regularly visits a doctor
  • Requires regular prescription medication

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 Plans

Blue Choice Preferred Gold PPO 204 – 2023 Plan Summary

2023 Plan Summary

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
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 deductibleThis 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 $9,100; Non-Participating Unlimited
Family: Participating $18,200; Non- Participating Unlimited
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?
No.You can see the specialist you choose without a referral.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

$15/visit; deductible does not apply

50% Coinsurance

Virtual Visits:$15/visit. See your benefit booklet* for details.
Specialist visit

$50/visit; deductible does not apply

50% Coinsurance

None
Preventive care/screening/immunization

No Charge; deductible does not apply

50% Coinsurance

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)

Freestanding Facility: 20%
coinsurance
Hospital: 30% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Imaging (CT / PET scans, MRIs)

Freestanding Facility: 20%
coinsurance
Hospital: 30% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about
prescription drug coverage is available here.
Preferred generic drugs

Retail -Preferred -No
Charge
Non-Preferred –
$10/prescription
Mail – No Charge; deductible
does not apply

Retail – $10/prescription;
deductible does not apply
Limited 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.
All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details.

 

Any differences between the cost of the generic drug and the cost of the brand name drug will apply to the deductible or out-of-pocket maximum.

The applicable cost sharing (by tier) and the cost difference between the generic and brand will never exceed the overall cost of the drug. 

The amount you may pay per 30-day supply of a covered insulin drug, regardless of quantity or type, shall not exceed $100, when obtained from a Participating Pharmacy.

Non-preferred generic drugs

Retail -Preferred – $10/prescription
Non-Preferred – $20/prescription
Mail – $30/prescription;
deductible does not apply

Retail – $20/ prescription;
deductible does not apply
Preferred brand drugs

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

Retail – 30% coinsurance

Non-preferred brand drugs

Preferred – 35% coinsurance
Non-Preferred – 40%
coinsurance

Retail – 40% coinsurance

Preferred specialty drugs

45% coinsurance

45% coinsurance

Non-preferred specialty drugs

50% coinsurance

50% coinsurance

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

Freestanding Facility: 20%
coinsurance
Hospital: 30% coinsurance

$2,000/visit plus 50%
coinsurance

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

30% coinsurance

50% coinsurance

If you need immediate
medical attention
Emergency room care

$1,000/visit plus 30%
coinsurance

$1,000/visit plus 30%
coinsurance

Per occurrence copayment waived upon inpatient admission. None
Emergency medical transportation

30% coinsurance

30% coinsurance

Preauthorization may be required for nonemergency transportation; see your benefit booklet* for details.
Urgent care

$50/visit; deductible does not apply

50% coinsurance

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

$850/visit plus 30%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required

 

Preauthorization required. Preauthorization penalty: $1,000 or 50% of the eligible charge In- Network, $500 Out-of-Network. See your benefit booklet* for details.

Physician/surgeon fee

30% Coinsurance

50% Coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services$15/office visits; deductible
does not apply
20% coinsurance for other outpatient services

50% coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Inpatient services

$850/visit plus 30%
coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required.
If you are pregnantOffice visits

Primary Care: $15
Specialist: $50; deductible
does not apply

50% coinsurance

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

30% coinsurance

50% coinsurance

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 30%
coinsurance

$2,000/visit plus 50%
coinsurance

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

30% coinsurance

50% coinsurance

Preauthorization may be required.
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

Preauthorization may be required.
Hospice service30% coinsurance

50% coinsurance

Preauthorization may be required.
If your child needs
dental or eye care
Children’s eye exam

No Charge; deductible does not apply

Up to a $30 reimbursement
is available; deductible does
not apply

One visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details
Children’s glasses

No Charge; deductible does not apply

Up to a $75 reimbursement is
available; deductible does not apply

One pair of glasses per year up to age 19. Reimbursement for frames, lenses and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for
details.
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.
  • Routine eye care
  • 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 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 foot care (only in connection with diabetes)

Blue Choice Preferred Gold Plans

Blue Choice Preferred Gold PPO 707 – 2023 Plan Summary

2023 Plan Summary

Important Questions Answers Why this Matters:
What is the overall deductible?Individual: Participating $2,000; Non-Participating $15,000
Family: Participating $4,000; Non-participating $45,000
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 deductibleThis 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 $8,700; Non-Participating Unlimited
Family: Participating $17,400; Non- Participating Unlimited
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?
No.You can see the specialist you choose without a referral.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
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

50% Coinsurance

Virtual Visits:$30/visit. See your benefit booklet* for details.
Specialist visit

$60/visit; deductible does not apply

50% Coinsurance

None
Preventive care/screening/immunization

No Charge; deductible does not apply

50% Coinsurance

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)

25% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Imaging (CT / PET scans, MRIs)

25% coinsurance

50% Coinsurance

Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about
prescription drug coverage is available here.
Generic drugs

Retail – $15/prescription
Mail – $45/prescription; deductible
does not apply

Retail – $15/prescription;
deductible does not apply
Limited 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.
All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details.

 

Any differences between the cost of the generic drug and the cost of the brand name drug will apply to the deductible or out-of-pocket maximum.

The applicable cost sharing (by tier) and the cost difference between the generic and brand will never exceed the overall cost of the drug. 

The amount you may pay per 30-day supply of a covered insulin drug, regardless of quantity or type, shall not exceed $100, when obtained from a Participating Pharmacy.

Preferred brand drugs

Retail – Preferred – $30/prescription
Mail – $90/prescription; deductible
does not apply

Retail – $30/ prescription;
deductible does not apply
Non-Preferred brand drugs

Retail – Preferred – $60/prescription
Mail – $180/prescription; deductible does not apply

Retail – $60/prescription; deductible does not apply

Specialty drugs$250/prescription; deductible does not apply

$250/prescription; deductible does not apply

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

25% coinsurance

$2,000/visit plus 50%
coinsurance

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

25% coinsurance

50% coinsurance

If you need immediate
medical attention
Emergency room care

25% coinsurance

25% coinsurance

None
Emergency medical transportation

25% coinsurance

25% coinsurance

Preauthorization may be required for nonemergency transportation; see your benefit booklet* for details.
Urgent care

$45/visit; deductible does not apply

50% coinsurance

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

25% coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required

 

Preauthorization required. Preauthorization penalty: $1,000 or 50% of the eligible charge In- Network, $500 Out-of-Network. See your benefit booklet* for details.

Physician/surgeon fee

25% coinsurance

50% Coinsurance

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services$30/office visits; deductible
does not apply
25% coinsurance for other outpatient services

50% coinsurance

Preauthorization may be required; see your benefit booklet* for details.
Inpatient services

25% coinsurance

$2,000/visit plus 50%
coinsurance

Preauthorization required.
If you are pregnantOffice visits

Primary Care: $30
Specialist: $60; deductible
does not apply

50% coinsurance

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

25% coinsurance

50% coinsurance

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

25% coinsurance

$2,000/visit plus 50%
coinsurance

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

25% coinsurance

50% coinsurance

Preauthorization may be required.
Rehabilitation services

$30/visit; deductible does not apply

50% coinsurance

Habilitation services

$30/visit; deductible does not apply

50% coinsurance

Skilled nursing care

25% coinsurance

50% coinsurance

Durable medical equipment

25% coinsurance

50% coinsurance

Preauthorization may be required.
Hospice service25% coinsurance

50% coinsurance

Preauthorization may be required.
If your child needs
dental or eye care
Children’s eye exam

No Charge; deductible does not apply

Up to a $30 reimbursement
is available; deductible does
not apply

One visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details
Children’s glasses

No Charge; deductible does not apply

Up to a $75 reimbursement is
available; deductible does not apply

One pair of glasses per year up to age 19. Reimbursement for frames, lenses and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for
details.
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.
  • Routine eye care
  • 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 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 foot care (only in connection with diabetes)