Blue Choice Preferred Silver PPO℠ 203 – PPO
94% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: No charge
Specialist visit: 30% coinsurance
Urgent care visit: $10 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $900 per person $1,800 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | 30% coinsurance |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $10 copay |
| Emergency room | $500 copay, 30% coinsurance |
| Ambulance | 30% coinsurance |
| Hospital stay (facility) | $250 copay per Stay, 30% coinsurance |
| Hospital stay (physician) | 30% coinsurance |
| Outpatient procedure (facility) | $100 copay, 10% coinsurance |
| Outpatient procedure (physician) | $50 copay, 30% coinsurance |
| Physical rehabilitation | 30% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $250 copay, 30% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | 30% coinsurance |
| Non-preferred Brand | 35% coinsurance |
| Specialty | 45% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 10% coinsurance |
| Imaging (CT/PET/MRI) | 10% coinsurance |
| Blood work | 10% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% coinsurance |
| Psychiatric hospital stay | $250 copay per Stay, 30% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsil.com/sbc/ind/sbc-sp6h30bceiilp-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 |
