Medical
This summary is an overview of your benefits only. Refer to your plan booklet for a complete description of benefits provided. The plan booklet and your eligibility for benefits will determine how your benefits are paid.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Blue Choice Options Plan
Benefit Highlights
Tier 1
Deductible (Individual/Family) $500/$1,500
Out-of-Pocket Max (Individual/Family) $1,500/$4,500
Preventive Care $0
Primary Care Visit $30 copay
Specialist Visit $40 copay
Emergency Room $100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic $15 copay
Preferred Brand $25 copay
Non-Preferred Brand $40 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic $30 copay
Preferred Brand $50 copay
Non-Preferred Brand $80 copay
Network
Deductible (Individual/Family) $750/$2,250
Out-of-Pocket Max (Individual/Family) $2,000/$6,000
Preventive Care $0
Primary Care Visit $40 copay
Specialist Visit $50 copay
Emergency Room $100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic $15 copay
Preferred Brand $25 copay
Non-Preferred Brand $40 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic $30 copay
Preferred Brand $50 copay
Non-Preferred Brand $80 copay
Out-of-Network*
Deductible (Individual/Family) $1,000/$3,000
Out-of-Pocket Max (Individual/Family) $3,000/$9,000
Preventive Care 40% after deductible
Primary Care Visit 40% after deductible
Specialist Visit 40% after deductible
Emergency Room $100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic $15 copay + 25%
Preferred Brand $25 copay + 25%
Non-Preferred Brand $40 copay + 25%
Mail-Order Rx (Up to 90-Day Supply)
Generic Not covered
Preferred Brand Not covered
Non-Preferred Brand Not covered
Plan Cost
BCBS of IL HMO Illinois Plan
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$30 Copay
Specialist Visit
$40 Copay
Emergency Room
$100 Copay
(Waived if Admitted to Inpatient)
Retail Rx (Up to 34-Day Supply)
Generic
$15 Copay
Preferred Brand
$30 Copay
Non-Preferred Brand
$55 Copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 Copay
Preferred Brand
$60 Copay
Non-Preferred Brand
$110 Copay
Plan Cost
BCBS of IL Blue Advantage HMO Plan
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$30 Copay
Specialist Visit
$40 Copay
Emergency Room
$100 Copay
(Waived if Admitted to Inpatient)
Retail Rx (Up to 30-Day Supply)
Generic
$15 Copay
Preferred Brand
$30 Copay
Non-Preferred Brand
$55 Copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 Copay
Preferred Brand
$60 Copay
Non-Preferred Brand
$110 Copay