Blue Precision Gold HMO℠ 703 – Rx Copays – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $40 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,000 per person $2,000 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | $1000 copay after deductible, 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | $750 copay per Day |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $300 copay after deductible, 30% coinsurance after deductible |
| Outpatient procedure (physician) | $40 copay |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $750 copay |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $60 copay |
| Non-preferred Brand | $120 copay |
| Specialty | $250 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay |
| Imaging (CT/PET/MRI) | $250 copay |
| Blood work | $40 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | $750 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsil.com/sbc/ind/sbc-ghsa32baviilp-il-2024.pdf |
| Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_IL_6T_HMO_HIM.pdf |
| Search doctor list | https://my.providerfinderonline.com/?ci=il-blueprecisionhmo-retail&corp_code=IL |
