Blue Choice Preferred Bronze PPO℠ 701 – Rx Copays – PPO

Network type: PPO
Coverage tier: Expanded Bronze
Primary care visit: No charge after deductible
Specialist visit: 50% coinsurance after deductible
Urgent care visit: 50% coinsurance after deductible

Description

Health Care Plan Details

Network type PPO
Deductible $9,000 per person $9,000 per person
Out-of-pocket max $9,450 per person $18,900 per family
Metal tier Expanded Bronze

Visit Copay

Primary care visit No charge after deductible
Specialist visit 50% coinsurance after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care 50% coinsurance after deductible
Emergency room $1000 copay after deductible, 50% coinsurance after deductible
Ambulance No charge after deductible
Hospital stay (facility) $850 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician) 50% coinsurance after deductible
Outpatient procedure (facility) $600 copay after deductible, 40% coinsurance after deductible
Outpatient procedure (physician) $200 copay after deductible, 50% coinsurance after deductible
Physical rehabilitation 50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay $850 copay, 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $150 copay
Brand $300 copay
Non-preferred Brand $350 copay
Specialty $500 copay

Lab Tests and Diagnostic Procedures

X-rays 40% coinsurance after deductible
Imaging (CT/PET/MRI) 40% coinsurance after deductible
Blood work 40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services No charge after deductible
Psychiatric hospital stay $850 copay per Stay after deductible, 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.bcbsil.com/sbc/ind/sbc-bpsa31bceiilp-il-2024.pdf
Drug and medication plan formulary https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_IL_6T_HIM.pdf
Search doctor list https://my.providerfinderonline.com/?ci=il-bluechoicepreferredppo-retail&corp_code=IL