Blue PPO Silver Plan 003

Our Rating:

Benefit Highlight	Blue PPO Silver 003
Plan Features
Lifetime Maximum	Unlimited
Participating providers	PPO Network 90% of IL doctors; over 200 IL hospitals
Individual Deductible	$6,000
Family Deductible	$12,700
Coinsurance	100%
Out of Pocket Maximum Includes deductible	$6,000
Family Out of Pocket Maximum Includes deductible	$12,700
Office Visit Copay (Primary Care/Specialist)	$30 / $50 specialist
Medical Coverage Details
Inpatient Hospital Medical / Surgical Services Hospital Services and Hospital Diagnostic Testing	$250 copay then 100% after deductible
Outpatient Surgery	$200 copay then 100% after deductible
Emergency Room / Outpatient Emergency Care Physician and Hospital	$500 copay then 100% after deductible
Outpatient Hospital Diagnostic Testing	100% after deductible
Mental Illness & Substance Abuse Rehab (Outpatient Hospital/ Physician Care)	$30 copay
Mental Illness & Substance Abuse Treatment (Inpatient Hospital Care)	$250 copay then 100% coinsurance after deductible
Mental Illness & Substance Abuse Treatment (Inpatient Physician Care)	100% after deductible
Preventive Care	Covered at 100%, no copay
Maternity Coverage	$250 copay then 100% after deductible
Prescription Drugs
Preferred Generics	$0 copay
Non Preferred Generics	$10 copay
Preferred Formulary	$50 copay
Non-Preferred Formulary	$100 copay
Specialty	$150 copay
Prescription Drug Formulary	Standard
Cost Reductions
Tax Credit Eligible	Yes
Cost Sharing Eligible	No
HSA Eligibile	No
Outline of Coverage

Blue PPO Silver Plan 004

Our Rating:

Benefit Highlight	Blue PPO Silver 004
Plan Features
Lifetime Maximum	Unlimited
Participating providers	PPO Network 90% of IL doctors; over 200 IL hospitals
Individual Deductible	$3,000
Family Deductible	$9,000
Coinsurance	80%
Out of Pocket Maximum Includes deductible	$6,350
Family Out of Pocket Maximum Includes deductible	$12,700
Office Visit Copay (Primary Care/Specialist)	$30 / $50 specialist
Medical Coverage Details
Outpatient Surgery	$200 copay then 80% after deductible
Inpatient Hospital Medical / Surgical Services Hospital Services and Hospital Diagnostic Testing	$250 copay then 80% after deductible
Emergency Room / Outpatient Emergency Care Physician and Hospital	$500 copay then 80% after deductible
Outpatient Hospital Diagnostic Testing	80% after deductible
Mental Illness & Substance Abuse Rehab (Outpatient Hospital/ Physcian Care)	$30 copay
Mental Illness & Substance Abuse Treatment (Inpatient Hospital Care)	$250 copay then 80% coinsurance after deductible
Mental Illness & Substance Abuse Treatment (Inpatient Physician Care)	80% coinsurance after deductible
Preventive Care	Covered at 100%, no copay
Maternity Coverage	$200 copay then 80% after deductible
Prescription Drugs
Preferred Generics	$0 copay
Non Preferred Generics	$10 copay
Preferred Formulary	$50 copay
Non-Preferred Formulary	$100 copay
Specialty	$150 copay
Prescription Drug Formulary	Standard
Cost Reductions
Tax Credit Eligible	Yes
Cost Sharing Eligible	No
HSA Eligibile	No
Outline of Coverage