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Blue Choice Preferred Gold PPO Plans
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Blue Choice Preferred Gold PPO Plans offers 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 that is was discontinued beginning January 1st, 2016. If you can accept some reduced hospital and physician choices, Blue Choice Preferred Gold PPO may be a great option for you.
The differences are how much your premium costs each month, what portion of the bill you pay for things like hospital visits or prescription medications, and how much your total out-of-pocket costs are. Blue Choice Preferred Gold PPO Plans have a higher monthly premium and often lower out-of-pocket costs than Blue Choice Preferred Silver plans. The Blue Choice Preferred PPO Gold Plans use the Blue Choice Preferred PPO network, a smaller PPO network that includes about 50% of doctors and hospitals in Illinois.
Blue Choice Preferred Gold PPO Plans:
- Blue Choice Preferred Gold Plan 204 Rx Copays – $750 individual / $1,500 family deductible and 30% coinsurance
- Blue Choice Preferred Gold Plan 707 – $1,500 individual / $3,000 family deductible and 25% coinsurance
Learn more about valuable member services and features you get when you join the Blue Cross and Blue Shield of Illinois family.
See toggles below for plan comparisons. Information is based on Participating Providers. For Non-Participating Provider information, please download the plan summaries listed above.
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Deductibles
204 Rx Copays | 707 | |
Overall Deductible Individual/Family | $750 / $1,500 | $1,500 / $3,000 |
Are there services covered before you meet deductible | Yes. | Yes. |
Are there other deductibles for specific services | No. | No. |
Out-of-pocket limit Individual/Family** | $9,450 / $18,900 | $8,700 / $17,400 |
Will you pay less if you use network provider? | Yes. | Yes. |
Referral to see a specialist? | No. | No. |
**Premiums, balance billing & health care this plan doesn’t cover are not included in the out-of-pocket limit
Office Visit / Testing
204 Rx Copays | 707 | |
Primary Care for injury/illness | $15/visit | $30/visit |
Specialist visit | 30% | $60/visit |
Preventative care/screening | No Charge | No Charge |
Diagnostic test (xray, blood) Freestanding Facility / Hospital | 20% / 30% | 25% |
Imaging (CT/PET/MRI) Freestanding Facility / Hospital | 20% / 30% | 25% |
**Premiums, balance billing & health care this plan doesn’t cover are not included in the out-of-pocket limit
Generic / Brand / Specialty Drug Comparison
If you need Drugs to treat your illness or condition. For information on whether or not deductibles apply, please download the plan summaries
204 Rx Copays | 707 | |
Generic Drugs (Preferred) | $20 / $60 | $15 / $45 |
Generic Drugs (Non Preferred) | $30 / $90 | $15 / $45 |
Brand drugs (Preferred) | $60 / $180 | $30 / $90 |
Brand Drugs Non Preferred | $120 / $360 | $60 / $180 |
Specialty Drugs Preferred | $250 | $250 |
Specialty Drugs Non Preferred | $350 | $250 |
Outpatient Surgery / Emergency Comparison
204 Rx Copays | 707 | |
Facility Fee Freestanding | 20% | 25% |
Facility fee Hospital | 30% | 25% |
Physician/surgeon Fee | 30% | 25% |
Emergency Room Care | $1,000/visit + 30% | 25% |
Emergency Medical Transportation | 30% | 25% |
Urgent Care | $25/visit | $45/visit |
Hospital Stay / Health Services / Pregnancy
204 Rx Copays | 707 | |
Facility Fee for hospital stay | $850/visit | 25% |
Physician/surgeon Fees | 30% | 25% |
Mental health, behavioral health, or substance abuse services: Outpatient | 30% office / 20% other | $30 office / 25% other |
Mental health, behavioral health, or substance abuse services: Inpatient | $850/visit + 30% | 25% |
If you are pregnant – office visit | Primary: $15 / Specialist: 30% | Primary: $30 / Specialist: $60 |
Childbirth/delivery/professional services | 30% | 25% |
Childbirth/delivery facility services | $850/visit + 30% | 25% |
Help recovering / other special needs
204 Rx Copays | 707 | |
Home Health Care | 30% | 25% |
Rehabilitation Services | 30% | $30/visit |
Habilitation services | 30% | $30/visit |
Skilled nursing care | 30% | 25% |
Durable medical equipment | 30% | 25% |
Hospice services | 30% | 25% |
Childrens Dental / Eye care
204 Rx Copays | 707 | |
Children’s eye exam | No Charge | No Charge |
Children’s Glasses | No Charge | No Charge |
Children’s Dental check-up | Not Covered | Not Covered |
Excluded & 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.)
204 Rx Copays | 707 | |
Acupuncture | ✓ | ✓ |
Dental Care (Adult) | ✓ | ✓ |
Long-term Care | ✓ | ✓ |
Non-emergency care when traveling outside of US | ✓ | ✓ |
Routine eye care (adult) | ✓ | ✓ |
Weight loss programs | ✓ | ✓ |
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
204 Rx Copays | 707 | |
Abortion care | ✓ | ✓ |
Bariatric surgery | ✓ | ✓ |
Chiropractic care | ✓ | ✓ |
Cosmetic surgery | ✓ | ✓ |
Hearing aids | ✓ | ✓ |
Infertility treatment | ✓ | ✓ |
Private-duty nursing | ✓ | ✓ |
Routine Foot Care | ✓ | ✓ |
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