Blue Choice Preferred Bronze PPOв„  201

Health Insurance Plan Details (2024 Plan)

by Blue Cross Blue Shield of Illinois

Monthly Premium

PPO
$ubsidy
Bronze
Deductible
$7,000 /yr
Max Out-of-Pocket
$9,450 /yr

Details

Deductible (per individual) $7,000 /yr
Deductible (per family) $14,000 /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 PPO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $45 Copay
Specialist Visit 50% Coinsurance after deductible
Emergency Room $1000 Copay with deductible and 50% Coinsurance after deductible
Inpatient Facility $850 Copay per Stay with deductible and 50% Coinsurance after deductible
Inpatient Physician 50% Coinsurance after deductible
Drug Costs
Generic Drugs $10 Copay
Preferred Brand Drugs 30% Coinsurance after deductible
Non-preferred Brand Drugs 35% Coinsurance after deductible
Specialty Drugs 45% 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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