Blue Choice Preferred Bronze PPO℠ 708 - 36096IL0990334 Health Insurance Plan

Blue Cross Blue Shield of Illinois health insurance plan with the Plan ID 36096IL0990334. The plan is called Blue Choice Preferred Bronze PPO℠ 708.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.39% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.61% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 36096IL0990334
Health Insurance Plan Year 2024
State Illinois
Health Insurance Issuer Blue Cross Blue Shield of Illinois
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 36096IL0990334-03
Provider Network(s) PREFERRED BLUE-CHOICE-PREFERRED-PPO NON-PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT).

Providers Illinois All US States
All 12696 105050
PCP 5 273
Allergy N/A N/A
OB/GYN N/A 12
Dentists 11 189
Available Variants of the Health Plan

Standard Off Exchange Plan - 36096IL0990334-00

Standard On Exchange Plan - 36096IL0990334-01

Open to Indians below 300% FPL - 36096IL0990334-02

Open to Indians above 300% FPL - 36096IL0990334-03

Last Plan Update Date Fri, 01 Sep 2023 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, 36096IL0990334-03

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Accidental Dental
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 25.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Cosmetic Surgery

Covered only for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care

Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable.

YES

50.00% Coinsurance after deductible

$2000.00 Copay with deductible, 50.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dialysis
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Exclusions: Not covered under the hospice program.

Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Provider-designated frames are covered. An allowance may apply to non-provider-designated frames. Coinsurance may apply to non-provider-designated frames on the remaining balance over the allowance. When purchasing Out of Network, reimbursements are available. See benefit book for details.

YES

No Charge

100.00% Coinsurance after deductible
Gender Affirming Care
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, OTC Equivalents, and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Certain generic drugs may have a higher cost share amount than is listed on this page. When prescription drugs are bought from an out of network pharmacy additional charges may apply. See benefit book for details.

YES

$25.00

$25.00
Habilitation Services

Therapy Services - Speech, Occupational and Physical; coverage for services provided by a physician or therapist.

YES

$50.00

50.00% Coinsurance after deductible
Hearing Aids

1 hearing aid per ear every 24 months under 19 and 19 and over they get $2500 per ear every 24 months.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Home Health Care Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment

Limit: 4.0 Procedure(s) per Benefit Period

4 completed oocyte retrievals per benefit period.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infusion Therapy

Member cost share may increase when using a Hospital based facility for these services. See benefit booklet for details.

YES

$100.00

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

50.00% Coinsurance after deductible

$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
YES

$50.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, OTC Equivalents, and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

YES

$100.00 Copay after deductible

$100.00 Copay after deductible
Nutritional Counseling

Covered for Preventive and Diabetes services only.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$100.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

YES

50.00% Coinsurance after deductible

$2000.00 Copay with deductible, 50.00% Coinsurance after deductible
Outpatient Rehabilitation Services
YES

$50.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, OTC Equivalents, and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

YES

$50.00 Copay after deductible

$50.00 Copay after deductible
Prenatal and Postnatal Care

First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.

YES

$50.00

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

0.00%

50.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness
YES

$50.00

50.00% Coinsurance after deductible
Private-Duty Nursing

Exclusions: Inpatient excluded

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Prosthetic Devices
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$50.00

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy
YES

$50.00

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

When purchasing Out of Network, reimbursements are available. See benefit book for details.

YES

No Charge

100.00%
Routine Foot Care

Covered when medically necessary.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Skilled Nursing Facility
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$100.00

50.00% Coinsurance after deductible
Specialty Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, OTC Equivalents, and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Certain specialty drugs may have a higher cost share amount than is listed on this page. If prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

YES

$500.00 Copay after deductible

$500.00 Copay after deductible
Substance Abuse Disorder Inpatient Services
YES

50.00% Coinsurance after deductible

$2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

$50.00

50.00% Coinsurance after deductible
Transplant
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Urgent Care Centers or Facilities
YES

$75.00

50.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan Variant 36096IL0990334-03 Attributes

Plan Attribute Value
AV Calculator Output Number 0.6438551469779571
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Limited Cost Sharing Plan Variation
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 0.997292689802625
First Tier Utilization 100%
Formulary ID ILF024
Formulary URL URL
HIOS Product ID 36096IL099
Import Date 2023-09-01 20:01:51
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 36096
Issuer Marketplace Marketing Name Blue Cross and Blue Shield of Illinois
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network Yes
Network ID ILN001
Out of Country Coverage Yes
Out of Country Coverage Description This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description When accessing care outside our service area, you will obtain care from healthcare Providers that have a contractual agreement (i.e., are Participating Providers) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (Host Blue). In some instances, you may obtain care from Non-Participating Providers.
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan ID (Standard Component ID with Variant) 36096IL0990334-03
Plan Marketing Name Blue Choice Preferred Bronze PPO℠ 708
Plan Type PPO
Plan Variant Marketing Name Blue Choice Preferred Bronze PPO℠ 708
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ILS041
Source Name SERFF
Plan ID 36096IL0990334
State Code IL
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $15000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $45000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $15000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $15,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9400 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,400
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, 36096IL0990334

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue Choice Preferred Bronze PPO℠ 708, 36096IL0990334 Health Insurance Plan, 36096IL0990334

  • Does Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, 36096IL0990334 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (36096IL0990334) Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (36096IL0990334) Health Insurance Plan, Variant (36096IL0990334-03) have Out Of Country Coverage?

    Yes. Details: This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs.

    Does (36096IL0990334) Health Insurance Plan, Variant (36096IL0990334-03) have Out of Service Area Coverage?

    Yes. Details: When accessing care outside our service area, you will obtain care from healthcare Providers that have a contractual agreement (i.e., are Participating Providers) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (Host Blue). In some instances, you may obtain care from Non-Participating Providers.

    Does (36096IL0990334) Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs for Asthma?

    Yes, the Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan Variant 36096IL0990334-03 offers Disease Management Program for Asthma.

    Does Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs for Heart disease?

    Yes, the Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan Variant 36096IL0990334-03 offers Disease Management Program for Heart disease.

    Does Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs for Depression?

    Yes, the Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan Variant 36096IL0990334-03 offers Disease Management Program for Depression.

    Does Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs for Diabetes?

    Yes, the Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan Variant 36096IL0990334-03 offers Disease Management Program for Diabetes.

    Does Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan Variant 36096IL0990334-03 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs for Low back pain?

    Yes, the Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan Variant 36096IL0990334-03 offers Disease Management Program for Low back pain.

    Does Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan, Variant (36096IL0990334-03) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Choice Preferred Bronze PPO℠ 708 Health Insurance Plan Variant 36096IL0990334-03 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API