Blue Choice Preferred Silver PPO℠ 706 – PPO

Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $60 copay

Description

Health Care Plan Details

Network type PPO
Deductible $5,900 per person $5,900 per person
Out-of-pocket max $9,100 per person $18,200 per family
Metal tier Silver

Visit Copay

Primary care visit $40 copay
Specialist visit $80 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $60 copay
Emergency room 40% coinsurance after deductible
Ambulance 40% coinsurance after deductible
Hospital stay (facility) 40% coinsurance after deductible
Hospital stay (physician) 40% coinsurance after deductible
Outpatient procedure (facility) 40% coinsurance after deductible
Outpatient procedure (physician) 40% coinsurance after deductible
Physical rehabilitation $40 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $20 copay
Brand $40 copay
Non-preferred Brand $80 copay after deductible
Specialty $350 copay after deductible

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 $40 copay
Psychiatric hospital stay 40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.bcbsil.com/sbc/ind/sbc-spsa45bceiilp-il-2024.pdf
Drug and medication plan formulary https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_IL_4T_HIM.pdf
Search doctor list https://my.providerfinderonline.com/?ci=il-bluechoicepreferredppo-retail&corp_code=IL