Blue Precision Silver HMO
- Blue Precision Silver HMO 206
- Blue Precision Silver HMO 306
- Overview
- Blue Precision Silver HMO 706
- Blue Precision Silver HMO 704rx
Blue Precision Silver HMO 206
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $4,400 Family: Participating $8,800 |
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? |
No | You don’t have to meet deductibles for specific services. |
| What is the out-of-pocket limit for this plan? |
Individual: Participating $9,450 Family: Participating $18,900 |
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 Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
$35/visit; deductible does not apply |
Not Covered |
None |
| Specialist visit |
$65/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 test | Diagnostic 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 |
Generic drugs (preferred) |
No Charge after deductible |
Not Covered | 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 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. |
| Generic drugs (non preferred) |
10% coinsurance |
|||
| Preferred brand drugs |
20% coinsurance |
Not Covered |
||
| Non-preferred brand drugs |
30% coinsurance |
Not Covered |
||
| Specialty drugs (preferred) |
40% coinsurance |
Not Covered |
||
| Specialty drugs (non preferred) |
50% coinsurance |
Not Covered |
||
| 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 |
$35/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 |
$65/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% |
Not Covered |
Referral required. |
| Physician/surgeon fee |
No Charge; deductible does |
Not Covered |
||
| If you have mental health, behavioral health, or substance abuse needs |
Outpatient services |
$35/office visits; deductible |
Not Covered |
Referral required. Telepsychiatry benefits are available; see your benefit booklet* for details. |
| Inpatient services |
$500/visit plus 50% |
Not Covered |
None | |
| If you are pregnant | Office visits |
Primary Care: $35 |
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 |
$35 /visit; deductible does not apply |
Not Covered |
||
| Habilitation services | $35/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 service | 50% 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.
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.) |
|
| 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.) |
|
Blue Precision Silver HMO 306
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $6,000 Family: Participating $12,000 |
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? |
No | You don’t have to meet deductibles for specific services. |
| What is the out-of-pocket limit for this plan? |
Individual: Participating $9,450 Family: Participating $18,900 |
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 Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
$15/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 test | Diagnostic 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 |
N/A | 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
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 – $20/prescription |
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% |
Not Covered |
Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees |
$200/visit; deductible does |
Not Covered |
||
| If you need immediate medical attention |
Emergency room care |
$1,000/visit plus 50% coinsurance |
$1,000/visit plus 50% |
Per occurrence copayment waived upon inpatient admission. |
| Emergency medical transportation |
50% coinsurance |
50% 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) |
$850/visit plus 50% |
Not Covered |
Referral required. |
| Physician/surgeon fee |
No Charge; deductible does |
Not Covered |
||
| If you have mental health, behavioral health, or substance abuse needs |
Outpatient services |
$15/office visits; deductible |
Not Covered |
Referral Required.
Telepsychiatry benefits are available; see your benefit booklet* for details. |
| Inpatient services |
$850/visit plus 50% |
Not Covered |
None | |
| If you are pregnant | Office visits |
Primary Care: $15 |
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 |
$15 /visit; deductible does not apply |
Not Covered |
||
| Habilitation services | $15/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 service | 50% 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.) |
|
| 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.) |
|
Blue Precision Silver HMO Plans
Our Rating: 
The plans below 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. Silver plans may be for you if you want to pay less out-of-pocket for care, qualify for a premium tax credit (also known as a subsidy), have a spouse/children on your health plan, or have regular medical needs.
Below is a summary of the five Blue Precision Silver Plan Options. Please visit the tabs above to see plan information in detail.
There are 4 Silver HMO plans:
- Blue Precision Silver HMO 206– $2,250 individual deductible and 50% coinsurance, $35 PCP copays
- Blue Precision Silver HMO 306 – $6,000 individual deductible and 50% coinsurance, $15 PCP copays
- Blue Precision Silver HMO 704 Rx Copays – $7,500 individual deductible and 50% coinsurance, $100 PCP copays
- Blue Precision Silver HMO 706 – $5,900 individual deductible and 40% coinsurance, $40 PCP copays
Blue Precision Silver HMO 706
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $5,900 Family: Participating $11,800 |
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? |
No | You don’t have to meet deductibles for specific services. |
| What is the out-of-pocket limit for this plan? |
Individual: Participating $9,100 Family: Participating $18,200 |
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 Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
$40/visit; deductible does not apply |
Not Covered |
None |
| Specialist visit |
$80/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 test | Diagnostic test (x-ray, blood work) |
40% coinsurance |
Not Covered |
Referral Required. |
| Imaging (CT / PET scans, MRIs) |
40% coinsurance |
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 |
Generic drugs |
Retail – $20/prescription |
Not Covered | 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 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 – $40/prescription |
Not Covered | ||
| Non-Preferred Brand Drugs |
Retail – Preferred – $80/prescription |
Not Covered |
||
| Specialty Drugs |
$350/prescription |
Not Covered |
||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
40% coinsurance |
Not Covered |
Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees |
40% coinsurance |
Not Covered |
||
| If you need immediate medical attention |
Emergency room care |
40% coinsurance |
40% coinsurance |
Per occurrence copayment waived upon inpatient admission. |
| Emergency medical transportation |
40% coinsurance |
40% coinsurance |
None | |
| Urgent care |
$60/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) |
40% coinsurance |
Not Covered |
Referral required. |
| Physician/surgeon fee |
No Charge; deductible does |
Not Covered |
||
| If you have mental health, behavioral health, or substance abuse needs |
Outpatient services |
$40/office visits; deductible |
Not Covered |
Referral required. Telepsychiatry benefits are available; see your benefit booklet* for details. |
| Inpatient services |
40% coinsurance |
Not Covered |
None | |
| If you are pregnant | Office visits |
Primary Care: $40 |
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 |
40% 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 |
$40/visit; deductible does not apply |
Not Covered |
||
| Habilitation services | $40/visit; deductible does not apply |
Not Covered |
||
| Skilled nursing care |
40% coinsurance |
Not Covered |
||
| Durable medical equipment |
No Charge; deductible does not apply |
Not Covered |
Referral required. | |
| Hospice service | 40% 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.) |
|
| 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.) |
|
Blue Precision Silver HMO 704rx
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $7,500 Family: Participating $15,000 |
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? |
No | You don’t have to meet deductibles for specific services. |
| What is the out-of-pocket limit for this plan? |
Individual: Participating $9,450 Family: Participating $18,900 |
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 Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
$100/visit; deductible does not apply |
Not Covered |
None |
| Specialist visit |
$130/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 test | Diagnostic test (x-ray, blood work) |
$90/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 – $25/prescription |
N/A | 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
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 – $70/prescription |
N/A | ||
| Preferred brand drugs |
Retail – $85/prescription |
N/A |
||
| Non-preferred brand drugs |
Retail – $120/prescription |
N/A |
||
| Preferred specialty drugs |
$250/prescription; deductible does not apply |
N/A |
||
| Non-preferred specialty drugs |
$500/prescription; deductible does not apply |
N/A |
||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
$350/visit plus 50% |
Not Covered |
Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees |
$90/visit; deductible does |
Not Covered |
||
| If you need immediate medical attention |
Emergency room care |
$1,200/visit plus 50% coinsurance |
$1,000/visit plus 50% |
Per occurrence copayment waived upon inpatient admission. |
| Emergency medical transportation |
50% coinsurance |
50% coinsurance |
None | |
| Urgent care |
$130/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% |
Not Covered |
Referral required. |
| Physician/surgeon fee |
No Charge; deductible does |
Not Covered |
||
| If you have mental health, behavioral health, or substance abuse needs |
Outpatient services |
$100/office visits; deductible |
Not Covered |
Referral required. Telepsychiatry benefits are available; see your benefit booklet* for details. |
| Inpatient services |
$500/visit plus 50% |
Not Covered
|
Referral required | |
| If you are pregnant | Office visits |
Primary Care: $100 |
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 |
$100 /visit; deductible does not apply |
Not Covered |
||
| Habilitation services | $100/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 service | 50% 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.) |
|
| 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.) |
|
