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.

There is only 1 Blue Choice Preferred Gold PPO Plan:
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.

Key Blue Choice Preferred Gold PPO® plan features include:
  • $20 primary care copays
  • $40 specialist copays
  • Maternity Coverage
  • Well-adult care
  • Well-child care
  • Diagnostic testing
  • Hospital services
  • Optional dental coverage
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

Compare the features, options and costs of BCBSIL Gold 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.

Add-ons and Plan Options

You can customize any Gold plan to add-on dental insurance.

Optional Dental Coverage

  • Covers cleanings, check-ups and other preventive procedures immediately – no waiting period
  • One of the highest maximum benefit amounts available – up to $1,500 per person per year
  • Up to 20% discount for orthodontic services at participating providers
  • Learn more about optional dental coverage

Blue Choice Gold Plan Costs

Health insurance costs include monthly premium payments, individual/family deductibles, out-of-pocket expenses, copayments, and coinsurance. Here is what you can expect with Blue Choice Gold® plans:

  • Individual in-network deductibles ranging from $1,000 to $3,250
  • $10 or $30 office visit copayments
  • $0 or $10 copayments for generic prescription drugs
  • Coinsurance of 100% to 80% percent of services provided in-network, after deductible and copayments are met
  • Annual out-of-pocket maximum of $3,250 and $3,500 for individuals and $9,750 or $10,500 for families, depending on the plan

By using a contracting BCBS PPO hospital, doctor or specialist you are able to save on premiums and the cost of covered services. You do not need to select a primary care physician or obtain a referral to see a specialist.

For more information on costs, get a quick quote or see the benefit summary.

Plan Renewals

Your BCBSIL policy can ONLY be terminated for the following reasons:

  • Failure to pay
  • The plan is discontinued (90 days notice given with an option to convert to any plan we offer)
  • Discovery of fraud or an intentional misrepresentation of facts (30 days prior written notice given)
  • If you no longer reside, live or work in an area where we are authorized to do business

Prescription Drug Coverage

For the Blue PPO Gold and Blue Choice Gold Plans, there is a prescription drug card benefit that includes a $0 or $10 copay for generic, $35 or $75 copay for formulary drugs, and a $150 copay for specialty medications. This benefit is immediately available and not subject to a deductible.

There is a also a Home Delivery prescription benefit available with these 3 deductible options where you can receive a 90 day supply in the mail for the cost of a 60 day supply and is subject to a maximum cost of $300 per prescription.

Outpatient Prescription Drug BenefitGold Plan 001Gold Plan 002
Preferred Generics$0 copay$0 copay
Non-Preferred Generics$10 copay$10 copay
Preferred Formulary$35 copay$35 copay
Non-Preferred Formulary$75 copay$75 copay
Specialty$150 copay$150 copay
Home Delivery
Up to a 90-day supply of maintenance drugs is available through home delivery and is subject to $300 maximum per prescription.
Preferred Generics$0 copay$0 copay
Non-Preferred Generics$20 copay$20 copay
Preferred Formulary$70 copay$70 copay
Non-Preferred Formulary$150 copay$150 copay
Specialty$300 copay$300 copay

What’s Included with Blue PPO Gold Plans®

  • Coverage for major hospital, medical and surgical expenses incurred as a result of a covered accident or sickness
  • Coverage for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care
  • Although you can go to the hospital or doctor of your choice, your benefits under a Blue Choice Gold® plan will be higher, and your costs lower, when you use the services of participating BlueChoice® PPO providers.
  • Maternity Coverage
  • As with all individual Blue Cross and Blue Shield of Illinois plans, the freedom of not having to select a primary care doctor or obtain a referral to see a specialist

More Plan Details

It’s important to know the critical features of the health plan you are considering. Each plan’s Outline of Coverage provides brief descriptions of the basic provisions the Blue Choice Gold plans, as well as details on policy renewability, benefit exclusions and coverage limitations.

Blue Choice Preferred Gold Plans

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
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 $8,550; Non-Participating Unlimited
Family: Participating $17,100; 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:$40/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.

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

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)