- Overview
- Blue Choice Preferred Silver PPO 203
- Blue Choice Preferred Silver PPO 303
- Blue Choice Preferred Silver PPO 706
Blue Choice Preferred Silver PPO Plans
Our Rating: 
Blue Choice Preferred Silver 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 and the largest PPO network BCBSIL offers to individual health plans. If you can accept some reduced hospital and physician choice, Blue Choice Preferred Silver PPO may be a great option for you. All Blue Choice Preferred Silver PPO plans offer the same set of essential health benefits, quality and amount of care.
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 Silver PPO Plans have a higher monthly premium and often lower out-of-pocket costs than Blue Choice Preferred Silver plans.
There are 3 Blue Choice Preferred Silver PPO Plans:
- Blue Choice Preferred Silver Plan 203 – $2,250 individual deductible and 50% coinsurance
- Blue Choice Preferred Silver Plan 303 – $2,250 individual deductible and 50% coinsurance
- Blue Choice Preferred Silver Plan 706 – $5,800 individual deductible and 40% coinsurance
- Both use the 6 tier formulary
Blue Choice Preferred PPO Network
The Blue Choice Preferred PPO Silver Plans use the Blue Choice Preferred PPO network, a smaller PPO network that includes about 68% of doctors and hospitals in Illinois.
Blue Choice Preferred Silver PPO Plans may be right for you if you are an individual or family who:
- Seeks coverage comparable to what is offered by employers
- Prefers fixed doctor visit copayments
- Regularly visits a doctor
- Requires regular prescription medication
Compare the features, options and costs of Blue Choice Preferred Silver® PPO 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 Silver PPO 203
2023 Plan Summary
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $2,250; Non-Participating $15,000 Family: Participating $6,750; 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 $9,100; Non-Participating Unlimited Family: Participating $18,200; 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 | Your cost if you use | 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 | $10/visit; deductible does not apply | 50% Coinsurance | Virtual Visits:$10/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: 30% | 50% Coinsurance | Preauthorization may be required; see your benefit booklet* for details. |
| Imaging (CT / PET scans, MRIs) | Freestanding Facility: 30% | 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 – | Retail – $10/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.
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. 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 Participating Pharmacy. |
| Non-preferred generic drugs | Retail – Preferred – $15/prescription | Retail – $25/ prescription; deductible does not apply | ||
| Preferred brand drugs | Preferred – 30% coinsurance | Retail – 35% coinsurance | ||
| Non-preferred brand drugs | Preferred – 35% 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: | $2,000/visit plus 50% | Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees | $200/visit plus 50% | 50% coinsurance | ||
| If you need immediate medical attention | Emergency room care | $1,000/visit plus 50% | $1,000/visit plus 50% | 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 | $15/visit; deductible does not apply | 50% coinsurance | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | $850/visit plus 50% | $2,000/visit plus 50% | 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. |
| 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; 30% coinsurance for other outpatient services | 50% coinsurance | Preauthorization may be required; see your benefit booklet* for details. |
| Inpatient services | $850/visit plus 50% | $2,000/visit plus 50% | Preauthorization required | |
| If you are pregnant | Office visits | Primary Care: $10; | 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% | $2,000/visit plus 50% | 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 | 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 | 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 |
*For more information about limitations and exceptions, see the plan or policy document here.
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.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Blue Choice Preferred Silver PPO 303
2023 Plan Summary
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $2,250; Non-Participating $15,000 Family: Participating $6,750; 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 $9,100; Non-Participating Unlimited Family: Participating $18,200; 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 | Your cost if you use | 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 | $10/visit; deductible does not apply | 50% Coinsurance | Virtual Visits:$10/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: 30% | 50% Coinsurance | Preauthorization may be required; see your benefit booklet* for details. |
| Imaging (CT / PET scans, MRIs) | Freestanding Facility: 30% | 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 – | Retail – $10/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.
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. 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 Participating Pharmacy. |
| Non-preferred generic drugs | Retail -Preferred – $15/prescription | Retail – $25/ prescription; deductible does not apply | ||
| Preferred brand drugs | Preferred – 30% coinsurance | Retail – 35% coinsurance | ||
| Non-preferred brand drugs | Preferred – 35% 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: | $2,000/visit plus 50% | Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees | $200/visit plus 50% | 50% coinsurance | ||
| If you need immediate medical attention | Emergency room care | $1,000/visit plus 50% | $1,000/visit plus 50% | 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 | $15/visit; deductible does not apply | 50% coinsurance | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | $850/visit plus 50% | $2,000/visit plus 50% | 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. |
| 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; 30% coinsurance for other outpatient services | 50% coinsurance | Preauthorization may be required; see your benefit booklet* for details. |
| Inpatient services | $850/visit plus 50% | $2,000/visit plus 50% | Preauthorization required | |
| If you are pregnant | Office visits | Primary Care: $10; | 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% | $2,000/visit plus 50% | 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 | 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 | 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.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Blue Choice Preferred Silver PPO 706
2023 Plan Summary
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | Individual: Participating $5,800; Non-Participating $15,000 Family: Participating $11,600; 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 $8,900; Non-Participating Unlimited Family: Participating $17,800; 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 | Your cost if you use | 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/visit; deductible does not apply | 50% Coinsurance | Virtual Visits:$40/visit. See your benefit booklet* for details. |
| Specialist visit | $80/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) | 40% coinsurance | 50% Coinsurance | Preauthorization may be required; see your benefit booklet* for details. |
| Imaging (CT / PET scans, MRIs) | 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. | Generic drugs | Retail – $20/prescription | 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. 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. 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 Participating Pharmacy. |
| Preferred brand drugs | Retail – Preferred – $40/prescription | Retail – $40/ prescription; deductible does not apply | ||
| Non-Preferred brand drugs | Retail – Preferred – $80/prescription. Mail – $240/prescription | Retail – $80/prescription | ||
| Specialty Drugs | $350/prescription | $350/prescription | ||
| If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | 40% coinsurance | $2,000/visit plus 50% | Preauthorization may be required. For Outpatient Infusion Therapy, see your benefit booklet* for details. |
| Physician/surgeon fees | 40% coinsurance | 50% coinsurance | ||
| If you need immediate medical attention | Emergency room care | 40% coinsurance | 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 | $60/visit; deductible does not apply | 50% coinsurance | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | 40% coinsurance | $2,000/visit plus 50% | 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. |
| Physician/surgeon fee | 40% coinsurance | 50% coinsurance | ||
| If you have mental health, behavioral health, or substance abuse needs | Outpatient services | $40/office visit; deductible does not apply 40% coinsurance for other outpatient services | 50% coinsurance | Preauthorization may be required; see your benefit booklet* for details. |
| Inpatient services | 40% coinsurance | $2,000/visit plus 50% | Preauthorization required | |
| If you are pregnant | Office visits | Primary Care: $40; | 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 | 40% 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 | 40% coinsurance | $2,000/visit plus 50% | 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 | 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 | 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 | 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.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|