BlueCare Direct Silver℠ 212 with Advocate – Rx Copays – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $100 copay
Specialist visit: $130 copay
Urgent care visit: $130 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $7,500 per person $7,500 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $100 copay |
| Specialist visit | $130 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $130 copay |
| Emergency room | $1200 copay after deductible, 50% coinsurance after deductible |
| Ambulance | 50% coinsurance after deductible |
| Hospital stay (facility) | $500 copay per Stay after deductible, 50% coinsurance after deductible |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $350 copay after deductible, 50% coinsurance after deductible |
| Outpatient procedure (physician) | $90 copay |
| Physical rehabilitation | $100 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $500 copay, 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | $85 copay |
| Non-preferred Brand | $120 copay |
| Specialty | $250 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $90 copay |
| Imaging (CT/PET/MRI) | $250 copay |
| Blood work | $90 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $100 copay |
| Psychiatric hospital stay | $500 copay per Stay after deductible, 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsil.com/sbc/ind/sbc-shsh30bhdiilp-il-2024.pdf |
| Drug and medication plan formulary | https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_IL_6T_HMO_HIM.pdf |
| Search doctor list | https://my.providerfinderonline.com/?ci=il-bluecaredirect-retail&corp_code=IL |
