Blue Choice Preferred Gold PPO℠ 707

Health Insurance Plan Details (2024 Plan)

by Blue Cross Blue Shield of Illinois

Monthly Premium

PPO
$ubsidy
Gold
Deductible
$1,500 /yr
Max Out-of-Pocket
$8,700 /yr

Details

Deductible (per individual) $1,500 /yr
Deductible (per family) $3,000 /yr
Max Out-of-Pocket (per individual) $8,700 /yr
Max Out-of-Pocket (per family) $17,400 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type PPO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $30 Copay
Specialist Visit $60 Copay
Emergency Room 25% Coinsurance after deductible
Inpatient Facility 25% Coinsurance after deductible
Inpatient Physician 25% Coinsurance after deductible
Drug Costs
Generic Drugs $15 Copay
Preferred Brand Drugs $30 Copay
Non-preferred Brand Drugs $60 Copay
Specialty Drugs $250 Copay

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

Insurance Carrier Disclaimer

Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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