BlueCare Direct Silver℠ 212 with Advocate – Rx Copays – HMO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$3,150 per person $6,300 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	$60 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay
Emergency room	$500 copay after deductible, 50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	$500 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician)	No charge
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	$15 copay
Physical rehabilitation	$30 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$500 copay, 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	$40 copay
Non-preferred Brand	$100 copay
Specialty	$250 copay

Lab Tests and Diagnostic Procedures

X-rays	$20 copay
Imaging (CT/PET/MRI)	$200 copay
Blood work	$20 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay
Psychiatric hospital stay	$500 copay per Stay after deductible, 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsil.com/sbc/ind/sbc-sh5h30bhdiilp-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-bluecaredirect-retail&corp_code=IL