Blue Choice Preferred Bronze PPO

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Blue Choice Preferred PPO Bronze Plans

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Blue Choice Preferred PPO Bronze Plans offer a respectable PPO network of doctors and hospitals and the convenience of never needing a referral to see a specialist. Blue Choice Preferred PPO Plans are coupled with the Blue Choice Preferred PPO network, a smaller version of the “standard” Blue Cross Blue Shield of Illinois PPO network and the largest PPO network BCBSIL offers to individual health plans. If you can accept some reduced hospital and physician choice, a Blue Choice Preferred Bronze PPO plan may be a great option for you. Because the Bronze plans have the same out of pocket maximum as Gold and Silver plans in 2023, it is actually cheaper to purchase a Bronze plan than Gold or Silver if you had a catastrophic event or were hospitalized.

All Blue Choice Bronze plans offer the same set of essential health benefits, quality and amount of care. The Blue PPO Bronze Plans use the Blue Choice Preferred PPO network, a PPO network that includes over half of doctors and hospitals in Illinois.

Below is a summary of the five Blue Choice Preferred Bronze Plan Options. Please visit the tabs above to see plan information in detail.

Blue Choice Preferred Bronze Plan 201 – $7,000 individual deductible and 50% coinsurance
Blue Choice Preferred Bronze Plan 202 – $4,500 individual deductible and 40% coinsurance
Blue Choice Preferred Bronze Plan 601 – $7,500 individual deductible and 50% coinsurance
Blue Choice Preferred Bronze Plan 701 – $9,000 individual deductible and 50% coinsurance
Blue Choice Preferred Bronze Plan 708 – $7,500 individual deductible and 50% coinsurance

*Discontinued Plans:

Blue Choice Preferred Bronze Plan 302 – $6,350 individual deductible and 40% coinsurance
Blue Choice Preferred Bronze Plan 502 – $5,000 individual deductible and 50% coinsurance
Blue Choice Preferred Bronze Plan 705 – $9,100 individual deductible

Compare the features, options and costs of Bronze® plans to find the one that’s right for you.

Learn more about valuable member services and features you get when you join the Blue Cross and Blue Shield of Illinois family.

Blue Choice Preferred Bronze PPO 201

2024 Plan Summary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $7,000; Non-Participating $15,000 Family: Participating $14,000; Non-Participating $45,000	Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible
Are there services covered before you meet your deductible?	Yes. In-Network Preventive Health Care services and services with a copay are covered before you meet your deductible	This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?	No	You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?	Individual: Participating $9,450; Non-Participating Unlimited Family: Participating $18,900; Non- Participating Unlimited	The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?	Premiums, balance-billed charges, and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See www.bcbsil.com or call 1- 800-892-2803 for a list of Participating Providers.	This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider (You will pay the least)	Your cost if you use a Non-Participating Provider (You will pay the most)	Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness	$45/visit; deductible does not apply	50% Coinsurance	Virtual Visits:$45/visit. See your benefit booklet* for details.
	Specialist visit	50% Coinsurance	50% Coinsurance	None

	Preventive care/screening/immunization	No Charge; deductible does not apply	50% Coinsurance	You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test	Diagnostic test (x-ray, blood work)	Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you have a test	Imaging (CT / PET scans, MRIs)	Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available here.	Preferred generic drugs	Retail -Preferred – $10/ prescription Non-Preferred – $20/prescription Mail – $30/prescription; deductible does not apply	Retail – $20/prescription; deductible does not apply	Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copayment/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. The amount you may pay per 30-day supply of a covered insulin drug, regardless of quantity or type, shall not exceed $100, when obtained from a Preferred Participating or Participating Pharmacy.
	Non-preferred generic drugs	Retail -Preferred – $20/ prescription Non-Preferred – $30/prescription Mail – $60/prescription; deductible does not apply	Retail – $30/ prescription; deductible does not apply
	Preferred brand drugs	Preferred – 30% coinsurance Non-Preferred – 35% coinsurance	Retail – 35% coinsurance
	Non-preferred brand drugs	Preferred – 35% coinsurance Non-Preferred – 40% coinsurance	Retail – 40% coinsurance
	Preferred specialty drugs	45% coinsurance	45% coinsurance
	Non-preferred specialty drugs	50% coinsurance	50% coinsurance
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	Freestanding Facility: $600/visit plus 40% coinsurance Hospital: $600/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
If you have outpatient surgery	Physician/surgeon fees	$200/visit plus 50% coinsurance	50% coinsurance
If you need immediate medical attention	Emergency room care	$1,000/visit plus 50% coinsurance	$1,000/visit plus 50% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	50% coinsurance	50% coinsurance	Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details.
	Urgent care	$60/visit; deductible does not apply	50% coinsurance	None
If you have a hospital stay	Facility fee (e.g., hospital room)	$850/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required. Preauthorization required. Preauthorization penalty: $1,000 or 50% of the eligible charge In-Network, $500 Out-of-Network. See your benefit booklet* for details.
If you have a hospital stay	Physician/surgeon fee	50% coinsurance	50% coinsurance
If you have mental health, behavioral health, or substance abuse needs	Outpatient services	50% coinsurance for office visits; 40% coinsurance for other outpatient services	50% coinsurance	Preauthorization may be required; see your benefit booklet* for details.
	Inpatient services	$850/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required


If you are pregnant	Office visits	Primary Care: $45; deductible does not apply Specialist: 50% coinsurance	50% coinsurance	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
	Childbirth/delivery professional services	50% coinsurance	50% coinsurance	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
	Childbirth/delivery facility services	$850/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help recovering or have other special health needs	Home health care	50% coinsurance	50% coinsurance	Preauthorization may be required.
	Rehabilitation services	50% coinsurance	50% coinsurance
	Habilitation services	50% coinsurance	50% coinsurance
	Skilled nursing care	50% coinsurance	50% coinsurance
	Durable medical equipment	50% coinsurance	50% coinsurance	Preauthorization may be required.
	Hospice service	50% coinsurance	50% coinsurance	Preauthorization may be required.
If your child needs dental or eye care	Children’s eye exam	No Charge; deductible does not apply	Up to a $30 reimbursement is available; deductible does not apply	One visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s glasses	No Charge; deductible does not apply	Reimbursement is available; deductible does not apply	One pair of glasses per year up to age 19. Reimbursement for frames, lenses and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s dental check-up	Not Covered	Not Covered	None

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture
Dental care (Adult)
Long-term care
Non-emergency care when traveling outside the U.S.
Routine eye care
Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Abortion care
Bariatric surgery
Chiropractic care (limited to 25 visits per calendar year)
Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
Infertility treatment (covered for 4 procedures per benefit period)
Private-duty nursing (with the exception of inpatient private duty nursing)
Routine foot care (only in connection with diabetes)

Blue Choice Preferred Bronze PPO 202

2024 Plan Summary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $4,500; Non-Participating $15,000 Family: Participating $9,000; Non-Participating $45,000	Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible
Are there services covered before you meet your deductible?	Yes. In-Network Preventive Health Care services and services with a copay are covered before you meet your deductible	This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?	No	You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?	Individual: Participating $7,500; Non-Participating Unlimited Family: Participating $15,000; Non- Participating Unlimited	The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?	Premiums, balance-billed charges, and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See www.bcbsil.com or call 1- 800-892-2803 for a list of Participating Providers.	This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider (You will pay the least)	Your cost if you use a Non-Participating Provider (You will pay the most)	Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness	40% Coinsurance	50% Coinsurance	Virtual Visits:40% coinsurance. See your benefit booklet* for details.
	Specialist visit	40% Coinsurance	50% Coinsurance	None

	Preventive care/screening/immunization	No Charge; deductible does not apply	50% Coinsurance	You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test	Diagnostic test (x-ray, blood work)	Freestanding Facility: 30% coinsurance Hospital: 40% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you have a test	Imaging (CT / PET scans, MRIs)	Freestanding Facility: 30% coinsurance Hospital: 40% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available here.	Preferred generic drugs	Preferred – 20% coinsurance Non-Preferred – 25% coinsurance	Retail – 25% coinsurance	Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details.
	Non-preferred generic drugs	Preferred – 25% coinsurance Non-Preferred – 30% coinsurance	Retail – 30% coinsurance
	Preferred brand drugs	Preferred – 30% coinsurance Non-Preferred – 35% coinsurance	Retail – 35% coinsurance
	Non-preferred brand drugs	Preferred – 35% coinsurance Non-Preferred – 40% coinsurance	Retail – 40% coinsurance
	Preferred specialty drugs	45% coinsurance	45% coinsurance
	Non-preferred specialty drugs	50% coinsurance	50% coinsurance
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	Freestanding Facility: $600/visit plus 30% coinsurance Hospital: $600/visit plus 40% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
If you have outpatient surgery	Physician/surgeon fees	$200/visit plus 40% coinsurance	50% coinsurance
If you need immediate medical attention	Emergency room care	$1,000/visit plus 40% coinsurance	$1,000/visit plus 40% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	40% coinsurance	40% coinsurance	Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details
	Urgent care	40% coinsurance	50% coinsurance	None.
If you have a hospital stay	Facility fee (e.g., hospital room)	$850/visit plus 40% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required. Preauthorization required. Preauthorization penalty: $1,000 or 50% of the eligible charge In-Network, $500 Out-of-Network. See your benefit booklet* for details.
If you have a hospital stay	Physician/surgeon fee	40% Coinsurance	50% Coinsurance
If you have mental health, behavioral health, or substance abuse needs	Outpatient services	40% coinsurance for office visits; 30% coinsurance for other outpatient services	50% coinsurance	Preauthorization may be required; see your benefit booklet* for details.
	Inpatient services	$850/visit plus 40% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required.


If you are pregnant	Office visits	40% coinsurance	50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)
	Childbirth/delivery professional services	40% coinsurance	50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)
	Childbirth/delivery facility services	$850/visit plus 40% coinsurance	$2,000/visit plus 50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound)
If you need help recovering or have other special health needs	Home health care	40% coinsurance	50% coinsurance	Preauthorization may be required.
	Rehabilitation services	40% coinsurance	50% coinsurance
	Habilitation services	40% coinsurance	50% coinsurance
	Skilled nursing care	40% coinsurance	50% coinsurance
	Durable medical equipment	40% coinsurance	50% coinsurance	Preauthorization may be required.
	Hospice service	40% coinsurance	50% coinsurance	Preauthorization may be required.
If your child needs dental or eye care	Children’s eye exam	No Charge; deductible does not apply	Up to a $30 reimbursement is available; deductible does not apply	One visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s glasses	No Charge; deductible does not apply	Up to a $75 reimbursement is available after deductible	One pair of glasses per year up to age 19. Reimbursement for frames, lenses and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Dental check-up	Not Covered	Not Covered	None

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture
Dental care (Adult)
Long-term care
Non-emergency care when traveling outside the U.S.
Routine eye care
Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Abortion care
Bariatric surgery
Chiropractic care (limited to 25 visits per calendar year)
Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
Infertility treatment (covered for 4 procedures per benefit period)
Private-duty nursing (with the exception of inpatient private duty nursing)
Routine foot care (only in connection with diabetes)

Blue Choice Preferred Bronze PPO 601

2024 Plan Summary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $7,500; Non-Participating $15,000 Family: Participating $15,000; Non- Participating $45,000	Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible
Are there services covered before you meet your deductible?	Yes. In-Network Preventive Health Care services and services with a copay are covered before you meet your deductible	This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?	No	You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?	Individual: Participating $9,450; Non-Participating Unlimited Family: Participating $18,900; Non- Participating Unlimited	The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?	Premiums, balance-billed charges, and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See www.bcbsil.com or call 1- 800-892-2803 for a list of Participating Providers.	This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider (You will pay the least)	Your cost if you use a Non-Participating Provider (You will pay the most)	Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness	40% coinsurance	50% Coinsurance	Virtual Visits: 40% coinsurance. See your benefit booklet* for details.
	Specialist visit	50% coinsurance	50% Coinsurance	None

	Preventive care/screening/immunization	No Charge; deductible does not apply	50% Coinsurance	You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test	Diagnostic test (x-ray, blood work)	Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you have a test	Imaging (CT / PET scans, MRIs)	Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available here.	Preferred generic drugs	Retail – Preferred – $150/prescription Mail – $450/prescription; deductible does not apply	Retail – $150/prescription; deductible does not apply	Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details. Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs are limited to a 30-day supply except for certain FDA designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Any differences between the cost of the generic drug and the cost of the brand name drug will apply to the deductible or out-of-pocket maximum. The applicable cost sharing (by tier) and the cost difference between the generic and brand will never exceed the overall cost of the drug. All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copayment/coinsurance. Additional charge will not apply to any deductible or out-of pocket amounts. The amount you may pay per 30-day supply of a covered insulin drug, regardless of quantity or type, shall not exceed $100, when obtained from a Preferred Participating or Participating Pharmacy.
	Non-preferred generic drugs	Retail – Preferred – $175/prescription Mail – $525/prescription; deductible does not apply	Retail – $175/prescription; deductible does not apply
	Preferred brand drugs	Retail – $200/prescription Mail – $600/prescription; deductible does not apply	$200/Prescription; deductible does not apply
	Non-preferred brand drugs	Retail – $250/prescription Mail – $750/prescription; deductible does not apply	$250/Prescription; deductible does not apply
	Preferred specialty drugs	$275/prescription; deductible does not apply	$275/Prescription; deductible does not apply
	Non-preferred specialty drugs	$500/prescription; deductible does not apply	$500/Prescription; deductible does not apply
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	Freestanding Facility: $600/visit plus 40% coinsurance Hospital: $600/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
If you have outpatient surgery	Physician/surgeon fees	$200/visit plus 50% coinsurance	50% coinsurance
If you need immediate medical attention	Emergency room care	$1,000/visit plus 50% coinsurance	$1,000/visit plus 50% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	50% coinsurance	50% coinsurance	Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details.
	Urgent care	50% coinsurance	50% coinsurance	None
If you have a hospital stay	Facility fee (e.g., hospital room)	$850/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required. Preauthorization required. Preauthorization penalty: $1,000 or 50% of the eligible charge In-Network, $500 Out-of-Network.See your benefit booklet* for details.
If you have a hospital stay	Physician/surgeon fee	50% coinsurance	50% coinsurance
If you have mental health, behavioral health, or substance abuse needs	Outpatient services	40% coinsurance	50% coinsurance	Preauthorization may be required; see your benefit booklet* for details.
	Inpatient services	$850/visit plus 40% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required


If you are pregnant	Office visits	40% coinsurance	50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
	Childbirth/delivery professional services	50% coinsurance	50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
	Childbirth/delivery facility services	$850/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help recovering or have other special health needs	Home health care	50% coinsurance	50% coinsurance	Preauthorization may be required.
	Rehabilitation services	50% coinsurance	50% coinsurance
	Habilitation services	50% coinsurance	50% coinsurance
	Skilled nursing care	50% coinsurance	50% coinsurance
	Durable medical equipment	50% coinsurance	50% coinsurance	Preauthorization may be required.
	Hospice service	50% coinsurance	50% coinsurance	Preauthorization may be required.
If your child needs dental or eye care	Children’s eye exam	No Charge; deductible does not apply	Up to a $30 reimbursement is available; deductible does not apply	One visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s glasses	No Charge; deductible does not apply	Up to a $75 reimbursement is available	One pair of glasses per year up to age 19. Reimbursement for frames, lenses and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s dental check-up	Not Covered	Not Covered	None

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture
Dental care (Adult)
Long-term care
Non-emergency care when traveling outside the U.S.
Routine eye care
Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Abortion care
Bariatric surgery
Chiropractic care (limited to 25 visits per calendar year)
Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
Infertility treatment (covered for 4 procedures per benefit period)
Private-duty nursing (with the exception of inpatient private duty nursing)
Routine foot care (only in connection with diabetes)

Blue Choice Preferred Bronze PPO 701

2024 Plan Summary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $9,000; Non-Participating $15,000 Family: Participating $18,000; Non- Participating $45,000	Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible
Are there services covered before you meet your deductible?	Yes. In-Network Preventive Health Care services and services with a copay are covered before you meet your deductible	This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?	No	You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?	Individual: Participating $9,450; Non-Participating Unlimited Family: Participating $18,900; Non- Participating Unlimited	The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?	Premiums, balance-billed charges, and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See www.bcbsil.com or call 1- 800-892-2803 for a list of Participating Providers.	This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider (You will pay the least)	Your cost if you use a Non-Participating Provider (You will pay the most)	Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness	No Charge after deductible	50% Coinsurance	Virtual Visits:$40/visit. See your benefit booklet* for details.
	Specialist visit	50% coinsurance	50% Coinsurance	None

	Preventive care/screening/immunization	No Charge; deductible does not apply	50% Coinsurance	You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test	Diagnostic test (x-ray, blood work)	Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you have a test	Imaging (CT / PET scans, MRIs)	Freestanding Facility: 40% coinsurance Hospital: 50% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available here.	Preferred generic drugs	Retail – $150/prescription Mail – $450/prescription; deductible does not apply	$150/prescription; deductible does not apply	Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details. Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs are limited to a 30-day supply except for certain FDA designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Any differences between the cost of the generic drug and the cost of the brand name drug will apply to the deductible or out-of-pocket maximum. The applicable cost sharing (by tier) and the cost difference between the generic and brand will never exceed the overall cost of the drug. All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copayment/coinsurance. Additional charge will not apply to any deductible or out-of pocket amounts. The amount you may pay per 30-day supply of a covered insulin drug, regardless of quantity or type, shall not exceed $100, when obtained from a Preferred Participating or Participating Pharmacy.
	Non-preferred generic drugs	Retail – $175/prescription Mail – $525/prescription; deductible does not apply	$175/prescription; deductible does not apply
	Preferred brand drugs	Retail – $300/prescription Mail – $900/prescription; deductible does not apply	$300/prescription; deductible does not apply
	Non-preferred brand drugs	Retail – $350/prescription Mail – $1,050/prescription; deductible does not apply	$350/prescription; deductible does not apply
	Preferred specialty drugs	$500/prescription; deductible does not apply	$500/prescription; deductible does not apply
	Non-preferred specialty drugs	$700/prescription; deductible does not apply	$700/prescription; deductible does not apply
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	Freestanding Facility: $600/visit plus 40% coinsurance Hospital: $600/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
If you have outpatient surgery	Physician/surgeon fees	$200/visit plus 50% coinsurance	50% coinsurance
If you need immediate medical attention	Emergency room care	$1,000/visit plus 50% coinsurance	$1,000/visit plus 50% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	50%	No Charge after deductible	Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details.
	Urgent care	50% coinsurance	50% coinsurance	None
If you have a hospital stay	Facility fee (e.g., hospital room)	$850/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required. Preauthorization required. Preauthorization penalty: $1,000 or 50% of the eligible charge In-Network, $500 Out-of-Network. See your benefit booklet* for details.
If you have a hospital stay	Physician/surgeon fee	50% coinsurance	50% coinsurance
If you have mental health, behavioral health, or substance abuse needs	Outpatient services	No Charge for office visits; after deductible 40% coinsurance for other outpatient services	50% coinsurance	Preauthorization may be required; see your benefit booklet* for details.
	Inpatient services	$850/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required


If you are pregnant	Office visits	Primary Care: No Charge after deductible Specialist: 50% coinsurance	50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
	Childbirth/delivery professional services	50% coinsurance	50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
	Childbirth/delivery facility services	$850/visit plus 50% coinsurance	$2,000/visit plus 50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help recovering or have other special health needs	Home health care	50% coinsurance	50% coinsurance	Preauthorization may be required.
	Rehabilitation services	50% coinsurance	50% coinsurance
	Habilitation services	50% coinsurance	50% coinsurance
	Skilled nursing care	50% coinsurance	50% coinsurance
	Durable medical equipment	50% coinsurance	50% coinsurance	Preauthorization may be required.
	Hospice service	50% coinsurance	50% coinsurance	Preauthorization may be required.
If your child needs dental or eye care	Children’s eye exam	No Charge; deductible does not apply	Up to a $30 reimbursement is available; deductible does not apply	One visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s glasses	No Charge; deductible does not apply	Up to a $75 reimbursement is available	One pair of glasses per year up to age 19. Reimbursement for frames, lenses and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s dental check-up	Not Covered	Not Covered	None

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture
Dental care (Adult)
Long-term care
Non-emergency care when traveling outside the U.S.
Routine eye care
Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Abortion care
Bariatric surgery
Chiropractic care (limited to 25 visits per calendar year)
Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
Infertility treatment (covered for 4 procedures per benefit period)
Private-duty nursing (with the exception of inpatient private duty nursing)
Routine foot care (only in connection with diabetes)

Blue Choice Preferred Bronze PPO 708

2024 Plan Summary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $7,500; Non-Participating $15,000 Family: Participating $15,000; Non- Participating $45,000	Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible
Are there services covered before you meet your deductible?	Yes. In-Network Preventive Health Care services and services with a copay are covered before you meet your deductible	This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?	No	You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?	Individual: Participating $9,400; Non-Participating Unlimited Family: Participating $18,800; Non- Participating Unlimited	The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?	Premiums, balance-billed charges, and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See www.bcbsil.com or call 1- 800-892-2803 for a list of Participating Providers.	This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider (You will pay the least)	Your cost if you use a Non-Participating Provider (You will pay the most)	Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness	$50/visit; deductible does not apply	50% Coinsurance	Virtual Visits:$50/visit. See your benefit booklet* for details.
	Specialist visit	$100/visit; deductible does not apply	50% Coinsurance	None

	Preventive care/screening/immunization	No Charge; deductible does not apply	50% Coinsurance	You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test	Diagnostic test (x-ray, blood work)	50% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you have a test	Imaging (CT / PET scans, MRIs)	50% coinsurance	50% Coinsurance	Preauthorization may be required; see your benefit booklet* for details.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available here.	Generic drugs	Retail – $25/prescription Mail – $75/prescription; deductible does not apply	Retail – $25/prescription; deductible does not apply	Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. All Out-of-Network prescriptions are subject to a 50% additional charge after the applicable copay/coinsurance. Additional charge will not apply to any deductible or out-of-pocket amounts. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details.
	Preferred generic drugs	Retail – Preferred – $50/prescription Mail – $150/prescription	Retail – $50/prescription
	Non-Preferred brand drugs	Retail – Preferred – $100/prescription Mail – $300/prescription	Retail – $100/prescription
	Specialty Drugs	$500/prescription	$500/prescription


If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
If you have outpatient surgery	Physician/surgeon fees	50% coinsurance	50% coinsurance
If you need immediate medical attention	Emergency room care	50% coinsurance	50% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	50% coinsurance	50% coinsurance	Preauthorization may be required for non- emergency transportation; see your benefit booklet* for details.
	Urgent care	$75/visit; deductible does not apply	50% coinsurance	None
If you have a hospital stay	Facility fee (e.g., hospital room)	50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required. Preauthorization required. Preauthorization penalty: $1,000 or 50% of the eligible charge In-Network, $500 Out-of-Network. See your benefit booklet* for details.
If you have a hospital stay	Physician/surgeon fee	50% coinsurance	50% coinsurance
If you have mental health, behavioral health, or substance abuse needs	Outpatient services	$50/office visit; deductible does not apply 50% coinsurance for other outpatient services	50% coinsurance	Preauthorization may be required; see your benefit booklet* for details.
	Inpatient services	50% coinsurance	$2,000/visit plus 50% coinsurance	Preauthorization required


If you are pregnant	Office visits	Primary Care: $50 Specialist: $100; deductible does not apply	50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
	Childbirth/delivery professional services	50% coinsurance	50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
	Childbirth/delivery facility services	50% coinsurance	$2,000/visit plus 50% coinsurance	Cost sharing does not apply for certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help recovering or have other special health needs	Home health care	50% coinsurance	50% coinsurance	Preauthorization may be required.
	Rehabilitation services	$50/visit; deductible does not apply	50% coinsurance
	Habilitation services	$50/visit; deductible does not apply	50% coinsurance
	Skilled nursing care	50% coinsurance	50% coinsurance
	Durable medical equipment	50% coinsurance	50% coinsurance	Preauthorization may be required.
	Hospice service	50% coinsurance	50% coinsurance	Preauthorization may be required.
If your child needs dental or eye care	Children’s eye exam	No Charge; deductible does not apply	Up to a $30 reimbursement is available; deductible does not apply	One visit per year. Out-of-Network reimbursement will not exceed the retail cost. See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s glasses	No Charge; deductible does not apply	Up to a $75 reimbursement is available	One pair of glasses per year up to age 19. Reimbursement for frames, lenses and lens options purchased Out-of-Network is available (not to exceed the retail cost). See your benefit booklet* (Pediatric Vision Care Benefits) for details.
	Children’s dental check-up	Not Covered	Not Covered	None

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture
Dental care (Adult)
Long-term care
Non-emergency care when traveling outside the U.S.
Routine eye care
Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Abortion care
Bariatric surgery
Chiropractic care (limited to 25 visits per calendar year)
Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases)
Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months)
Infertility treatment (covered for 4 procedures per benefit period)
Private-duty nursing (with the exception of inpatient private duty nursing)
Routine foot care (only in connection with diabetes)