Blue Precision Gold HMO Plan


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Blue Precision Gold HMO Plan

Blue Precision – Gold HMO plans – 2023

Our Rating: Blue Precision Gold HMO Plan

You must select a Blue Precision HMO Network Primary Care Physician (PCP) when enrolling in these plans

There are 3 Gold HMO plans:
  • Gold HMO 207 – $750 deductible and 30% coinsurance
  • Gold HMO 707 – $950 deductible and 30% coinsurance
  • Gold HMO 703rx – $2,000 deductible and 25% coinsurance
PPO Network

The The Gold HMO Plan uses the Blue Precision HMO network, one the largest HMO network 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.

Key Gold HMO plan features include:
  • Lower out-of-pocket costs than PPO plans
  • You must select a network primary care physician (PCP), who coordinates your care within the network
  • Referral required to see a specialist
  • $20-30 doctor visit copayment for primary care physicians (PCPs) and $40-60 copay for specialists
  • Prescription drug coverage
  • Maternity Coverage
  • Well-adult care
  • Well-child care
  • Diagnostic testing
  • Hospital services
  • Access to the BlueCard PPO network when traveling out-of-state
Gold® may be right for you if you are an individual or family who:
  • Are willing to have a primary care physican (PCP) coordinate your care
  • Prefers fixed doctor visit copayments
  • Are not expecting to have surgery or major services in the near future
  • 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 Precision Gold HMO Plan

Blue Precision Gold HMO 207

 

Important Questions Answers Why this Matters:
What is the overall deductible?Individual:
Participating $750
Family:
Participating $2,250
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
copay mentor 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 I 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 the plan’s permission before you see the specialist.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider

Your cost if you use
a Non-Participating
Provider

Limitations & Exceptions
If you visit a health care provider’s office or clinicPrimary 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 testDiagnostic 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 apply

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 CoveredLimited 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%
coinsurance

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 services

$1,000 copayment/
visit plus 30%
coinsurance

$1,000 copayment/
visit plus 30%
coinsurance

Per occurrence copayment waived upon inpatient admission.
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 apply

Not Covered

Referral required.
Physician/surgeon fee

No Charge, deductible does not apply

Not Covered

If you need mental
health, behavioral health,
or substance abuse
services
Mental/Behavioral health outpatient services

$20/office visits; deductible
does not apply
30% coinsurance for other
outpatient services

Not Covered

Referral required. Telepsychiatry benefits are available; see your benefit booklet* for details.
Mental/Behavioral health inpatient services

$750/day; deductible does
not apply

Not Covered

None
If you are pregnantOffice visits

Primary Care: $20
Specialist: $40; 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 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

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

$500/day; deductible does
not apply

Not Covered

Durable medical equipment

No Charge; deductible does not apply

Not Covered

Referral required.
Hospice service30% coinsurance

Not Covered

Referral required.
If your child needs
dental or eye care
Eye exam

No Charge; deductible does
not apply

Not Covered

One visit per year. See your benefit booklet* for details.
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.
Dental check-up

Not Covered

Not Covered

None

 

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Weight loss programs
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.)
  • 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 eye care (Adult, 1 visit per benefit period)
  • Routine foot care (only in connection with diabetes)

Blue Precision Gold HMO Plan

Blue Precision Bronze HMO 205

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 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
copay mentor 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 $8,700
Family: Participating $17,400
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 EventServices You May Need

Your cost if you use
a Participating
Provider

Your cost if you use
a Non-Participating
Provider

Limitations & Exceptions
If you visit a health care provider’s office or clinicPrimary 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 testDiagnostic test (x-ray, blood work)

$100/lab, $150/X-Ray;
deductible does not apply

Not Covered

Referral Required.
Imaging (CT / PET scans, MRIs)

$300/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

10% coinsurance

N/ALimited 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

15% coinsurance

N/A
Preferred brand drugs

20% coinsurance

N/A

Non-preferred brand drugs

30% coinsurance

N/A

Preferred Specialty drugs

40% coinsurance

N/A

Non-preferred specialty drugs

50% coinsurance

N/A

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

$300/visit plus 50%
coinsurance.

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%
coinsurance

$1,000/visit plus 50%
coinsurance

Per occurrence copayment waived upon inpatient
admission.
Emergency medical transportation

50% coinsurance

50% coinsurance

None
Urgent Care$105/visit; deductible does not apply                Not Covered
If you have a hospital
stay
Facility fee (e.g., hospital room)

$850/day; deductible does not apply

Not Covered

Referral required.
Physician/surgeon fee

No Charge; deductible does not apply

Not Covered

If you need mental
health, behavioral health,
or substance abuse
services
Outpatient services

$65/office visits; deductible does not apply 50% coinsurance for other outpatient services

Not Covered

Telepsychiatry benefits are available; see your
benefit booklet* for details.
Inpatient services

$850/day; deductible does
not apply

Not Covered

None
If you are pregnantOffice visits

Primary Care: $65
Specialist: $105; 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 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 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).
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

$70 /visit; deductible does not apply

Not Covered

Habilitation services

$70/visit; deductible does not apply

Not Covered

Skilled nursing care

$500/day; deductible does not apply

Not Covered

Durable medical equipment

No Charge; deductible does not apply

Not Covered

Referral required.
Hospice service50% 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 benefit booklet* for network 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.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • 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 ofcongenital deformities or conditions resulting fromaccidental 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)
  • Infertility treatment (covered for 4 procedures per benefit period)
  • Private-duty nursing (with the exception of inpatient private duty nursing)
  • Routine eye care (Adult, 1 visit per benefit period)
  • Routine foot care (only in connection with diabetes)

Blue Precision Gold HMO Plan

Blue Precision Gold HMO 707

 

Important Questions Answers Why this Matters:
What is the overall deductible?Individual:
Participating $2,000
Family:
Participating $4,000
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
copay mentor 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 $8,700
Family:
Participating $17,400
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 I 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 the plan’s permission before you see the specialist.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider

Your cost if you use
a Non-Participating
Provider

Limitations & Exceptions
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

Not Covered

None
Specialist visit

$60/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 testDiagnostic test (x-ray, blood work)

25% coinsurance

Not Covered

Referral Required.
Imaging (CT / PET scans, MRIs)

25% coinsurance

Not Covered

Referral Required.
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

Not CoveredLimited 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

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

Not Covered
Preferred brand drugs

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

Not Covered

Specialty Drugs

$250/prescription; deductible does not
apply

Not Covered

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

25% coinsurance

Not Covered

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

25% coinsurance

Not Covered

If you need immediate
medical attention
Emergency room services

25% coinsurance

$1,000 copayment/
visit plus 30%
coinsurance

None
Emergency medical transportation

25% coinsurance

30% coinsurance

None
Urgent care

$45/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)

25% coinsurance

Not Covered

Referral required.
Physician/surgeon fee

No Charge, deductible does not apply

Not Covered

If you need mental
health, behavioral health,
or substance abuse
services
Mental/Behavioral health outpatient services

$30/office visits; deductible
does not apply
25% coinsurance for other
outpatient services

Not Covered

Telepsychiatry benefits are available; see your benefit booklet* for details.
Mental/Behavioral health inpatient services

25% coinsurance

Not Covered

Referral Required
If you are pregnantOffice visits

Primary Care: $30
Specialist: $60; 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 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

25% 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

$30 /visit; deductible does
not apply

Not Covered

Habilitation services

$30/visit; deductible does not
apply

Not Covered

Skilled nursing care

25% coinsurance

Not Covered

Durable medical equipment

No Charge; deductible does not apply

Not Covered

Referral required.
Hospice service25% coinsurance

Not Covered

Referral required.
If your child needs
dental or eye care
Eye exam

No Charge; deductible does
not apply

Not Covered

One visit per year. See your benefit booklet* for details.
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.
Dental check-up

Not Covered

Not Covered

None

 

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Weight loss programs
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.)
  • 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 eye care (Adult, 1 visit per benefit period)
  • Routine foot care (only in connection with diabetes)

Blue Precision Gold HMO Plan

Blue Precision Gold HMO 703rx

 

Important Questions Answers Why this Matters:
What is the overall deductible?Individual:
Participating $950
Family:
Participating $2,850
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
copay mentor 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 I 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 the plan’s permission before you see the specialist.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider

Your cost if you use
a Non-Participating
Provider

Limitations & Exceptions
If you visit a health care provider’s office or clinicPrimary 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 testDiagnostic 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 apply

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

Retail – $20/prescription
Mail – $60/prescription; deductible
does not apply

Not CoveredLimited 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

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

Not Covered
Preferred brand drugs

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

Not Covered

Non-preferred brand drugs

Retail – $120/prescription
Mail – $360/prescription; deductible
does not apply

Not Covered

Preferred specialty drugs

$250/prescription; deductible does not
apply

Not Covered

Non-preferred specialty drugs

$350/prescription; deductible does not
apply

Not Covered

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

$300/visit plus 30%
coinsurance

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 services

$1,000 copayment/
visit plus 30%
coinsurance

$1,000 copayment/
visit plus 30%
coinsurance

Per occurrence copayment waived upon inpatient admission.
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 apply

Not Covered

Referral required.
Physician/surgeon fee

No Charge, deductible does not apply

Not Covered

If you need mental
health, behavioral health,
or substance abuse
services
Mental/Behavioral health outpatient services

$20/office visits; deductible
does not apply
30% coinsurance for other
outpatient services

Not Covered

Telepsychiatry benefits are available; see your benefit booklet* for details.
Mental/Behavioral health inpatient services

$750/day

Not Covered

Referral required
If you are pregnantOffice visits

Primary Care: $20
Specialist: $40; 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 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

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

$500/day; deductible does
not apply

Not Covered

Durable medical equipment

No Charge; deductible does not apply

Not Covered

Referral required.
Hospice service30% coinsurance

Not Covered

Referral required.
If your child needs
dental or eye care
Eye exam

No Charge; deductible does
not apply

Not Covered

One visit per year. See your benefit booklet* for details.
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.
Dental check-up

Not Covered

Not Covered

None

 

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Acupuncture
  • Dental care (Adult)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Weight loss programs
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.)
  • 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 eye care (Adult, 1 visit per benefit period)
  • Routine foot care (only in connection with diabetes)