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 |