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- BlueCare Direct Bronze 401 with Advocate
- BlueCare Direct Gold 409 w/Advocate
- BlueCare Direct Silver 212 with Advocate
BLUECARE DIRECTSM
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 Bronze 401 with Advocate
2023 Plan Summary
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $7,400 Family: Participating $17,400 Doesn’t apply to preventive care & certain copayments. |
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 other 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 |
$65/visit; deductible does not apply |
Not Covered |
None |
| Specialist visit |
$105/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) |
$100/lab, $150/X-Ray; |
Not Covered |
Referral Required. |
| Imaging (CT / PET scans, MRIs) |
$300/test; deductible does |
Not Covered |
Referral Required. | |
| If you need drugs to treat your illness or condition More information about prescription drug coverage is available here. |
Preferred generic drugs |
10% coinsurance |
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 and a generic may also be required if a generic drug is available. 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 |
15% coinsurance |
Not Covered | ||
| Preferred brand drugs |
20% coinsurance |
Not Covered |
||
| Non-preferred brand drugs |
30% coinsurance |
Not Covered |
||
| Preferred specialty drugs |
40% coinsurance |
Not Covered |
||
| Non-preferred specialty drugs |
50% coinsurance |
Not Covered |
||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
$300/visit plus 50% |
Not Covered |
Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees |
$150/visit; deductible does not apply |
Not Covered |
||
| If you need immediate medical attention |
Emergency room care |
$1,000/visit plus 50% |
$1,000/visit plus 50% |
Per occurrence copayment waived upon inpatient admission. None |
| Emergency medical transportation |
50% coinsurance |
50% coinsurance |
None | |
| Urgent care |
$105/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/day; deductible does |
Not Covered |
Referral required. |
| Physician/surgeon fee |
No Charge; deductible does |
Not Covered |
||
| If you need mental health, behavioral health, or substance abuse services |
Outpatient services |
$65/office visits; deductible |
Not Covered |
Telepsychiatry benefits are available; see your benefit booklet* for details. |
| Inpatient services |
$850/day; deductible does |
Not Covered |
None | |
| If you are pregnant | Office visits |
Primary Care: $65 |
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/day; deductible does |
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 Covered |
Referral required. |
| Rehabilitation services |
$70 /visit; deductible does |
Not Covered |
||
| Habilitation services |
$70/visit; deductible does not apply |
Not Covered |
||
| Skilled nursing care |
$500/day; deductible does |
Not Covered |
||
| Durable medical equipment |
No Charge; deductible does |
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.) |
|
BlueCare Direct Gold 409 with Advocate
2023 Plan Summary
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $750 Family: Participating $2,250 Doesn’t apply to preventive care & certain copayments. |
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 other 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.comor 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 planwill pay some or all of the costs to see a specialistfor 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 |
$20/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) |
$40/test; deductible does not apply |
Not Covered |
Referral Required. |
| Imaging (CT / PET scans, MRIs) |
$250/test; deductible does |
Not Covered |
Referral Required. | |
| If you need drugs to treat your illness or condition More information about prescription drug coverage is available here. | Preferred generic drugs |
10% coinsurance |
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 and a generic may also be required if a generic drug is available. 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 |
15% coinsurance |
Not Covered | ||
| Preferred brand drugs |
20% coinsurance |
Not Covered |
||
| Non-preferred brand drugs |
30% coinsurance |
Not Covered |
||
| Preferred specialty drugs |
40% coinsurance |
Not Covered |
||
| Non-preferred specialty drugs |
50% coinsurance |
Not Covered |
||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
$300/visit plus 30% |
Not Covered |
Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees |
$40/visit; deductible does not apply |
Not Covered |
||
| If you need immediate medical attention |
Emergency room care |
$1,000/visit plus 30% |
$1,000/visit plus 30% |
Per occurrence copayment waived upon inpatient admission. None |
| Emergency medical transportation |
30% coinsurance |
30% 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) |
$750/day; deductible does |
Not Covered |
Referral required. |
| Physician/surgeon fee |
No Charge; deductible does |
Not Covered |
||
| If you need mental health, behavioral health, or substance abuse services |
Outpatient services |
$20/office visits; deductible |
Not Covered |
Telepsychiatry benefits are available; see your benefit booklet* for details. |
| Inpatient services |
$750/day; deductible does |
Not Covered |
None | |
| If you are pregnant | Office visits |
Primary Care: $20 |
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 |
$750/day; deductible does |
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 Covered |
Referral required. |
| Rehabilitation services |
$40 /visit; deductible does |
Not Covered |
||
| Habilitation services |
$40/visit; deductible does not apply |
Not Covered |
||
| Skilled nursing care |
$500/day; deductible does |
Not Covered |
||
| Durable medical equipment |
No Charge; deductible does |
Not Covered |
Referral required | |
| Hospice service | 30% 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.) |
|
BlueCare Direct Silver 212 with Advocate
2023 Plan Summary
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $4,600 Family: Participating $13,800 |
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 other 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.comor 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 |
$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) |
$250/test; deductible does |
Not Covered |
Referral Required. | |
| If you need drugs to treat your illness or condition More information about prescription drug coverage is available here. |
Preferred generic drugs |
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 and a generic may also be required if a generic drug is available. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details. |
| Non-preferred generic drugs |
10% coinsurance |
Not Covered | ||
| Preferred brand drugs |
20% coinsurance |
Not Covered |
||
| Non-preferred brand drugs |
30% coinsurance |
Not Covered |
||
| Preferred specialty drugs |
40% coinsurance |
Not Covered |
||
| Non-preferred specialty drugs |
50% coinsurance |
Not Covered |
||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
50% |
Not Covered |
Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees |
$30/visit; deductible does not apply |
Not Covered |
||
| If you need immediate medical attention |
Emergency room care |
$1,000/visit plus 50% |
$1,000/visit plus 50% |
Per occurrence copayment waived upon inpatient admission. None |
| 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% coinsurance |
Not Covered |
Referral required. |
| Physician/surgeon fee |
No Charge; deductible does |
Not Covered |
||
| If you need mental health, behavioral health, or substance abuse services |
Outpatient services |
$40/office visits; deductible |
Not Covered |
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: $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 |
$500/visit plus 50% |
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 Covered |
Referral required. |
| Rehabilitation services |
$30 /visit; deductible does |
Not Covered |
||
| Habilitation services |
$30/visit; deductible does not apply |
Not Covered |
||
| Skilled nursing care |
50% coinsurance |
Not Covered |
||
| Durable medical equipment |
No Charge; deductible does |
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.) |
|
