Blue Precision Silver HMO 704℠ - Rx Copays

Health Insurance Plan Details (2024 Plan)

by Blue Cross Blue Shield of Illinois

Monthly Premium

HMO
$ubsidy
Silver
Deductible
$7,500 /yr
Max Out-of-Pocket
$9,450 /yr

Details

Deductible (per individual) $7,500 /yr
Deductible (per family) $15,000 /yr
Max Out-of-Pocket (per individual) $9,450 /yr
Max Out-of-Pocket (per family) $18,900 /yr
Drug Deductible (per individual) $0
Drug Deductible (per family) $0
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $100 Copay
Specialist Visit $130 Copay
Emergency Room $1200 Copay with deductible and 50% Coinsurance after deductible
Inpatient Facility $500 Copay per Stay with deductible and 50% Coinsurance after deductible
Inpatient Physician No Charge
Drug Costs
Generic Drugs $25 Copay
Preferred Brand Drugs $85 Copay
Non-preferred Brand Drugs $120 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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