Blue Choice Preferred Gold PPO℠ 204 – Rx Copays – PPO

Network type: PPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: 30% coinsurance after deductible
Urgent care visit: $25 copay

Description

Health Care Plan Details

Network type PPO
Deductible $750 per person $750 per person
Out-of-pocket max $9,450 per person $18,900 per family
Metal tier Gold

Visit Copay

Primary care visit $15 copay
Specialist visit 30% coinsurance after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $25 copay
Emergency room $1000 copay after deductible, 30% coinsurance after deductible
Ambulance 30% coinsurance after deductible
Hospital stay (facility) $850 copay per Stay after deductible, 30% coinsurance after deductible
Hospital stay (physician) 30% coinsurance after deductible
Outpatient procedure (facility) 20% coinsurance after deductible
Outpatient procedure (physician) 30% coinsurance after deductible
Physical rehabilitation 30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay $850 copay, 30% coinsurance after deductible

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 20% coinsurance after deductible
Imaging (CT/PET/MRI) 20% coinsurance after deductible
Blood work 20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services 30% coinsurance after deductible
Psychiatric hospital stay $850 copay per Stay after deductible, 30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.bcbsil.com/sbc/ind/sbc-gpsh30bceiilp-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