Blue Precision Gold HMOв„  207

Health Insurance Plan Details (2024 Plan)

by Blue Cross Blue Shield of Illinois

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$750 /yr
Max Out-of-Pocket
$9,450 /yr

Details

Deductible (per individual) $750 /yr
Deductible (per family) $1,500 /yr
Max Out-of-Pocket (per individual) $9,450 /yr
Max Out-of-Pocket (per family) $18,900 /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 HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $20 Copay
Specialist Visit $40 Copay
Emergency Room $1000 Copay with deductible and 30% Coinsurance after deductible
Inpatient Facility $750 Copay per Day
Inpatient Physician No Charge
Drug Costs
Generic Drugs 10% Coinsurance after deductible
Preferred Brand Drugs 20% Coinsurance after deductible
Non-preferred Brand Drugs 30% Coinsurance after deductible
Specialty Drugs 40% Coinsurance after deductible

Plan Documents

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

* 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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