Blue Cross Blue Shield of Illinois Blue Precision Gold Hmo 207

Blue Precision HMO Plans

Our Rating:

All Blue Precision HMO Plans offer the same set of essential health benefits, quality and amount of care. The Blue Precision Gold HMO Plans are the most expensive plans, but also have the most comprehensive benefits. Gold Plans have a higher monthly premium and often lower out-of-pocket costs than Silver and Bronze plans. BCBSIL Blue Precision HMO Plans cover 100% of costs, while you only cover the copays for medical services in most cases. There are deductibles for this plan, and this is an HMO plan (when applicable for major services). You must select a Blue Precision HMO Network Primary Care Physician (PCP) when enrolling in this plan.

Blue Precision Gold HMO 207 Plan features:

• $750 single/$2,250 family deductible
• $20 doctor visit / $40 specialist copayment
• $40 urgent care copayment
• 10% charge for Tier 1 formulary generic drugs

Blue Precision Silver HMO 206 Plan features:

• $3,100 single/$9,300 family deductible
• $35 doctor visit / $75 specialist copayment
• $75 urgent care copayment
• No charge for Tier 1 formulary generic drugs

Blue Precision Silver HMO 306 Plan features:

• $3,300 single/$9,900 family deductible
• $30 doctor visit / $30 specialist copayment
• $30 urgent care copayment
• No charge for Tier 1 formulary generic drugs

Blue Precision Bronze HMO 205 Plan features:

• $7,400 single/$17,400 family deductible
• $65 doctor visit / $105 specialist copayment
• $105 urgent care copayment
• 10% charge for Tier 1 formulary generic drugs

HMO Network

The Blue Precision HMO Plans use the Blue Precision HMO network, one the largest HMO networks in Illinois. You must select a network primary care physician (PCP), who coordinates your care within the network and referrals are required from your PCP to see a specialists.

Key Blue Precision HMO® Plan features include:

• Lower out-of-pocket costs and monthly premiums than PPO plans
• May help keep your costs lower and more predictable
• You must select a network primary care physician (PCP), who coordinates your care within the network
• Referral required to see a specialist
• Prescription drug coverage
• Maternity Coverage
• Well-adult care
• Well-child care
• Diagnostic testing
• Hospital services
• Optional dental coverage

Blue Precision HMO® Plans may be right for you if you are an individual or family who:

• Are willing to have a primary care physician (PCP) coordinate your care
• Prefers fixed doctor visit copayments
• Are expecting to have surgery or major services in the near future and want the lowest out of pocket costs
• Requires regular prescription medication

Learn more about valuable member services and features you get when you join the Blue Cross and Blue Shield of Illinois family.

Blue Precision Bronze HMO 205

• Benefit Summary
• 2021 Formulary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $7,400 Family: Participating $17,400 Doesn't apply to preventive care & certain copayments.	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 copay mentor 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 $8,700 Family: Participating $17,400	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?	Yes.	This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider	Your cost if you use a Non-Participating Provider	Limitations & Exceptions
If you visit a health care provider's office or clinic	Primary care visit to treat an injury or illness	$65/visit; deductible does not apply	Not Covered	None
	Specialist visit	$105/visit; deductible does not apply	Not Covered	Referral Required.
	Preventive care/screening/immunization	No Charge; deductible does not apply	Not Covered	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)	$100/lab, $150/X-Ray; deductible does not apply	Not Covered	Referral Required.
	Imaging (CT / PET scans, MRIs)	$300/test; deductible does not apply	Not Covered	Referral Required.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsil.com/rx21h	Preferred generic drugs	10% coinsurance	N/A	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. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details.
	Non-preferred generic drugs	15% coinsurance	N/A
	Preferred brand drugs	20% coinsurance	N/A
	Non-preferred brand drugs	30% coinsurance	N/A
	Preferred Specialty drugs	40% coinsurance	N/A
	Non-preferred specialty drugs	50% coinsurance	N/A
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	$300/visit plus 50% coinsurance.	Not Covered	Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
	Physician/surgeon fees	$150/visit; deductible does not apply	Not Covered
If you need immediate medical attention	Emergency room care	$1,000/visit plus 50% coinsurance	$1,000/visit plus 50% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	50% coinsurance	50% coinsurance	None
	Urgent Care	$105/visit; deductible does not apply	Not Covered
If you have a hospital stay	Facility fee (e.g., hospital room)	$850/day; deductible does not apply	Not Covered	Referral required.
	Physician/surgeon fee	No Charge; deductible does not apply	Not Covered
If you need mental health, behavioral health, or substance abuse services	Outpatient services	$65/office visits; deductible does not apply 50% coinsurance for other outpatient services	Not Covered	Telepsychiatry benefits are available; see your benefit booklet* for details.
	Inpatient services	$850/day; deductible does not apply	Not Covered	None
If you are pregnant	Office visits	Primary Care: $65 Specialist: $105; deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	No Charge; deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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/day; deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	No Charge; deductible does not apply	Not Covered	Referral required.
	Rehabilitation services	$70 /visit; deductible does not apply	Not Covered
	Habilitation services	$70/visit; deductible does not apply	Not Covered
	Skilled nursing care	$500/day; deductible does not apply	Not Covered
	Durable medical equipment	No Charge; deductible does not apply	Not Covered	Referral required.
	Hospice service	50% coinsurance	Not Covered	Referral required.
If your child needs dental or eye care	Children's eye exam	No Charge; deductible does not apply	Not Covered	One visit per year. See benefit booklet* for network details.
	Children's glasses	No Charge; deductible does not apply	Not Covered	One pair of glasses up to age 19 per year. See your benefit booklet* 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.)

Acupuncture Dental care (Adult) Long-term care Non-emergency care when traveling outside the U.S. Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.

Abortion care Bariatric surgery Chiropractic care (limited to 25 visits per calendar year) Cosmetic surgery (only for the correction ofcongenital deformities or conditions resulting fromaccidental injuries, scars, tumors, or diseases) Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months) Infertility treatment (covered for 4 procedures per benefit period) Infertility treatment (covered for 4 procedures per benefit period) Private-duty nursing (with the exception of inpatient private duty nursing) Routine eye care (Adult, 1 visit per benefit period) Routine foot care (only in connection with diabetes)

Blue Precision Gold HMO 207

• Benefit Summary
• 2021 Formulary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $750 Family: Participating $2,250	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 copay mentor 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 $8,700 Family: Participating $17,400	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.comor 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 I need a referral to see a specialist?	Yes.	This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist .

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider	Your cost if you use a Non-Participating Provider	Limitations & Exceptions
If you visit a health care provider's office or clinic	Primary care visit to treat an injury or illness	$20/visit; deductible does not apply	Not Covered	None
	Specialist visit	$40/visit; deductible does not apply	Not Covered	Referral Required.
	Preventive care/screening/immunization	No Charge; deductible does not apply	Not Covered	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/test; deductible does not apply	Not Covered	Referral Required.
	Imaging (CT / PET scans, MRIs)	$250/test; deductible does not apply	Not Covered	Referral Required.
If you need drugs to treat your illness or conditionMore information about prescription drug coverage is available here.	Preferred generic drugs	10% coinsurance	Not Covered	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. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details.
	Non-preferred generic drugs	15% coinsurance	Not Covered
	Preferred brand drugs	20% coinsurance	Not Covered
	Non-preferred brand drugs	30% coinsurance	Not Covered
	Preferred specialty drugs	40% coinsurance	Not Covered
	Non-preferred specialty drugs	50% coinsurance	Not Covered
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	$300/visit plus 30% coinsurance	Not Covered	Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
	Physician/surgeon fees	$40/visit; deductible does not apply	Not Covered
If you need immediate medical attention	Emergency room services	$1,000 copayment/ visit plus 30% coinsurance	$1,000 copayment/ visit plus 30% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	30% coinsurance	30% coinsurance	None
	Urgent care	$40/visit; deductible does not apply	Not Covered	Must be affiliated with member's chosen medical group or referral required.
If you have a hospital stay	Facility fee (e.g., hospital room)	$750/day; deductible does not apply	Not Covered	Referral required.
	Physician/surgeon fee	No Charge, deductible does not apply	Not Covered
If you need mental health, behavioral health, or substance abuse services	Mental/Behavioral health outpatient services	$20/office visits; deductible does not apply 30% coinsurance for other outpatient services	Not Covered	Telepsychiatry benefits are available; see your benefit booklet* for details.
	Mental/Behavioral health inpatient services	$750/day; deductible does not apply	Not Covered	None
If you are pregnant	Office visits	Primary Care: $20 Specialist: $40; deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	No Charge; deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	$750/day; deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	No Charge; deductible does not apply	Not Covered	Referral required.
	Rehabilitation services	$40 /visit; deductible does not apply	Not Covered
	Habilitation services	$40/visit; deductible does not apply	Not Covered
	Skilled nursing care	$500/day; deductible does not apply	Not Covered
	Durable medical equipment	No Charge; deductible does not apply	Not Covered	Referral required.
	Hospice service	30% coinsurance	Not Covered	Referral required.
If your child needs dental or eye care	Eye exam	No Charge; deductible does not apply	Not Covered	One visit per year. See your benefit booklet* for details.
	Glasses	No Charge; deductible does not apply	Not Covered	One pair of glasses up to age 19 per year. See your benefit booklet* for details.
	Dental check-up	Not Covered	Not Covered	None

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)

Acupuncture Dental care (Adult) Long-term care Non-emergency care when traveling outside the U.S. Weight loss programs

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Abortion care Bariatric surgery Chiropractic care (limited to 25 visits per calendar year) Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases) Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months) Infertility treatment (covered for 4 procedures per benefit period) Private-duty nursing (with the exception of inpatient private duty nursing) Routine eye care (Adult, 1 visit per benefit period) Routine foot care (only in connection with diabetes)

Blue Precision Silver HMO 206

• Benefit Summary
• 2021 Formulary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $3,100 Family: Participating $9,300	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 $8,700 Family: Participating $17,400	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?	Yes.	This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider	Your cost if you use a Non-Participating Provider	Limitations & Exceptions
If you visit a health care provider's office or clinic	Primary care visit to treat an injury or illness	$35/visit; deductible does not apply	Not Covered	None
	Specialist visit	$75/visit; deductible does not apply	Not Covered	Referral Required.
	Preventive care/screening/immunization	No Charge; deductible does not apply	Not Covered	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)	$20/test; deductible does not apply	Not Covered	Referral Required.
	Imaging (CT / PET scans, MRIs)	$350/test; deductible does not apply	Not Covered	Referral Required.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsil.com/rx21h	Preferred generic drugs	No Charge after deductible	Not Covered	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. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details
	Non-preferred generic drugs	10% coinsurance	Not Covered
	Preferred brand drugs	20% coinsurance	Not Covered
	Non-preferred brand drugs	30% coinsurance	Not Covered
	Preferred specialty drugs	40% coinsurance	Not Covered
	Non-preferred specialty drugs	50% coinsurance	Not Covered
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	50% coinsurance	Not Covered	Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
	Physician/surgeon fees	$30/visit; deductible does not apply	Not Covered
If you need immediate medical attention	Emergency room care	$1,000/visit plus 50% coinsurance	$1,000/visit plus 50% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	50% coinsurance	50% coinsurance	None
	Urgent care	$75/visit; deductible does not apply	Not Covered	Must be affiliated with member's chosen medical group or referral required.
If you have a hospital stay	Facility fee (e.g., hospital room)	$500/visit plus 50% coinsurance	Not Covered	Referral required.
	Physician/surgeon fee	No Charge; deductible does not apply	Not Covered
If you have mental health, behavioral health, or substance abuse needs	Outpatient services	$30/office visits; deductible does not apply 50% coinsurance for other outpatient services	$30/office visits; deductible does not apply 50% coinsurance for other outpatient services	Telepsychiatry benefits are available; see your benefit booklet* for details.
	Inpatient services	$500/visit plus 50% coinsurance	$500/visit plus 50% coinsurance	None
If you are pregnant	Office visits	Primary Care: $35 Specialist: $75; deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	No Charge deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	$500/visit plus 50% coinsurance	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	No Charge; deductible does not apply	Not Covered	Referral required.
	Rehabilitation services	$30 /visit; deductible does not apply	Not Covered
	Habilitation services	$30/visit; deductible does not apply	Not Covered
	Skilled nursing care	50% coinsurance	Not Covered
	Durable medical equipment	No Charge; deductible does not apply	Not Covered	Referral required.
	Hospice service	50% coinsurance	Not Covered	Referral required.
If your child needs dental or eye care	Children's eye exam	No Charge; deductible does not apply	Not Covered	One visit per year. See your benefit booklet* for details.
	Children's glasses	No Charge; deductible does not apply	Not Covered	One pair of glasses up to age 19 per year. See your benefit booklet* 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.

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.)

Acupuncture Dental care (Adult) Long-term care Non-emergency care when traveling outside the U.S. Weight loss programs

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Abortion care Bariatric surgery Chiropractic care (limited to 25 visits per calendar year) Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases) Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months) Infertility treatment (covered for 4 procedures per benefit period) Private-duty nursing (with the exception of inpatient private duty nursing) Routine eye care (Adult, 1 visit per benefit period) Routine foot care (only in connection with diabetes)

Blue Precision Silver HMO 306

• Benefit Summary
• 2021 Formulary

Important Questions	Answers	Why this Matters:
What is the overall deductible?	Individual: Participating $3,300 Family: Participating $9,900	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 $8,700 Family: Participating $17,400	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?	Yes.	This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

Common Medical Event	Services You May Need	Your cost if you use a Participating Provider	Your cost if you use a Non-Participating Provider	Limitations & Exceptions
If you visit a health care provider's office or clinic	Primary care visit to treat an injury or illness	$30/visit; deductible does not apply	Not Covered	None
	Specialist visit	$30/visit; deductible does not apply	Not Covered	Referral Required.
	Preventive care/screening/immunization	No Charge; deductible does not apply	Not Covered	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)	$35/test; deductible does not apply	Not Covered	Referral Required.
	Imaging (CT / PET scans, MRIs)	$250/test; deductible does not apply	Not Covered	Referral Required.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsil.com/rx21h	Preferred generic drugs	Retail – $10/prescription Mail – $30/prescription; deductible does not apply	N/A	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. You may be eligible to synchronize your prescription refills, please see your benefit booklet* for details
	Non-preferred generic drugs	Retail – $20/prescription Mail – $60/prescription; deductible does not apply	N/A
	Preferred brand drugs	30% coinsurance	N/A
	Non-preferred brand drugs	40% coinsurance	N/A
	Preferred specialty drugs	45% coinsurance	N/A
	Non-preferred specialty drugs	50% coinsurance	N/A
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	$600/visit plus 50% coinsurance	Not Covered	Referral required. For Outpatient Infusion Therapy, see your benefit booklet* for details.
	Physician/surgeon fees	$200/visit; deductible does not apply	Not Covered
If you need immediate medical attention	Emergency room care	$1,000/visit plus 50% coinsurance	$1,000/visit plus 50% coinsurance	Per occurrence copayment waived upon inpatient admission.
	Emergency medical transportation	50% coinsurance	50% coinsurance	None
	Urgent care	$30/visit; deductible does not apply	Not Covered	Must be affiliated with member's chosen medical group or referral required.
If you have a hospital stay	Facility fee (e.g., hospital room)	$850/visit plus 50% coinsurance	Not Covered	Referral required.
	Physician/surgeon fee	No Charge; deductible does not apply	Not Covered
If you have mental health, behavioral health, or substance abuse needs	Outpatient services	$20/office visits; deductible does not apply 30% coinsurance for other outpatient services	$20/office visits; deductible does not apply 30% coinsurance for other outpatient services	Telepsychiatry benefits are available; see your benefit booklet* for details.
	Inpatient services	$850/visit plus 50% coinsurance	$850/visit plus 50% coinsurance	None
If you are pregnant	Office visits	Primary Care: $30 Specialist: $30; deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	No Charge deductible does not apply	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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% coinsurance	Not Covered	Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for 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	No Charge; deductible does not apply	Not Covered	Referral required.
	Rehabilitation services	$30 /visit; deductible does not apply	Not Covered
	Habilitation services	$30/visit; deductible does not apply	Not Covered
	Skilled nursing care	50% coinsurance	Not Covered
	Durable medical equipment	No Charge; deductible does not apply	Not Covered	Referral required.
	Hospice service	50% coinsurance	Not Covered	Referral required.
If your child needs dental or eye care	Children's eye exam	No Charge; deductible does not apply	Not Covered	One visit per year. See your benefit booklet* for details.
	Children's glasses	No Charge; deductible does not apply	Not Covered	One pair of glasses up to age 19 per year. See your benefit booklet* 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.)

Acupuncture Dental care (Adult) Long-term care Non-emergency care when traveling outside the U.S. Weight loss programs

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Abortion care Bariatric surgery Chiropractic care (limited to 25 visits per calendar year) Cosmetic surgery (only for the correction of congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases) Hearing aids (for children 1 per ear every 24 months, for adults up to $2,500 per ear every 24 months) Infertility treatment (covered for 4 procedures per benefit period) Private-duty nursing (with the exception of inpatient private duty nursing) Routine eye care (Adult, 1 visit per benefit period) Routine foot care (only in connection with diabetes)

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Source: https://www.ilhealthagents.com/bluecross-blueshield-illinois/blue-precision-hmo/

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