Blue Precision Bronze HMO℠ 701 - Rx Copays - 36096IL0810138 Health Insurance Plan
Blue Cross Blue Shield of Illinois health insurance plan with the Plan ID 36096IL0810138. The plan is called Blue Precision Bronze HMO℠ 701 - Rx Copays.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.97% (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 35.03% 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 | 36096IL0810138 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 36096IL0810138-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NON-PREFERRED BLUE-PRECISION-HMO | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 36096IL0810138-00 Standard On Exchange Plan - 36096IL0810138-01 |
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| Last Plan Update Date | Fri, 01 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, 36096IL0810138-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | 50.00% |
100.00% |
| Accidental Dental
|
YES | 50.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% |
100.00% |
| Bariatric Surgery
|
YES | 50.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Year |
YES | 50.00% |
100.00% |
| Cosmetic Surgery
Covered only for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases. |
YES | 50.00% |
100.00% |
| 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. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
YES | $1,500.00, 50.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 50.00% |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
|
YES | No Charge |
100.00% |
| Emergency Room Services
Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
YES | $2,000.00, 50.00% |
$2,000.00, 50.00% |
| 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% |
50.00% |
| 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. See benefit book for details. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 50.00% |
100.00% |
| 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. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details. |
YES | $100.00 |
100.00% |
| Habilitation Services
Therapy Services - Speech, Occupational and Physical; coverage for services provided by a physician or therapist. |
YES | $150.00 |
100.00% |
| 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% |
100.00% |
| Home Health Care Services
|
YES | No Charge |
100.00% |
| Hospice Services
|
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $450.00 |
100.00% |
| Infertility Treatment
Limit: 4.0 Procedure(s) per Benefit Period 4 completed oocyte retrievals per benefit period. |
YES | 50.00% |
100.00% |
| Infusion Therapy
Member cost share may increase when using a Hospital based facility for these services. See benefit booklet for details. |
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
YES | $1500.00 Copay per Day, 50.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $250.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
YES | $1500.00 Copay per Day, 50.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $150.00 |
100.00% |
| 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. Out of Network Pharmacy coverage is only available in emergency situations. 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 | $175.00 |
100.00% |
| Nutritional Counseling
Covered for Preventive and Diabetes services only. |
YES | 50.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $160.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Member will be responsible for copay per outpatient surgery admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
YES | $750.00, 50.00% |
100.00% |
| Outpatient Rehabilitation Services
|
YES | $150.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $400.00 |
100.00% |
| 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. Out of Network Pharmacy coverage is only available in emergency situations. 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 | $120.00 |
100.00% |
| 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 | $150.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $150.00 |
100.00% |
| Private-Duty Nursing
Exclusions: Inpatient excluded |
YES | 50.00% |
100.00% |
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
|
YES | 50.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $150.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $150.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Benefit Period |
YES | 50.00% |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
Covered when medically necessary. |
YES | 50.00% |
100.00% |
| Skilled Nursing Facility
|
YES | $800.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $160.00 |
100.00% |
| 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. Out of Network Pharmacy coverage is only available in emergency situations. 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 | $275.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
YES | $1500.00 Copay per Day, 50.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $150.00 |
100.00% |
| Transplant
|
YES | 50.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $160.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $250.00 |
100.00% |
Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan Variant 36096IL0810138-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6496850618487789 |
| 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 | Standard Bronze On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| 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 | 0.997289147754571 |
| First Tier Utilization | 100% |
| Formulary ID | ILF010 |
| Formulary URL | URL |
| HIOS Product ID | 36096IL081 |
| 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? | Yes |
| Issuer ID | 36096 |
| Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of Illinois |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ILN002 |
| 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 | Coverage outside our service area is available for Emergency and Urgent Care services only. |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 36096IL0810138-01 |
| Plan Marketing Name | Blue Precision Bronze HMO℠ 701 - Rx Copays |
| Plan Type | HMO |
| Plan Variant Marketing Name | Blue Precision Bronze HMO℠ 701 - Rx Copays |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2800 |
| 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 | $2900 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS072 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Referrals are required for some services. Please check with your Medical Group for details. |
| Plan ID | 36096IL0810138 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| 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 Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, 36096IL0810138
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Precision Bronze HMO℠ 701 - Rx Copays, 36096IL0810138 Health Insurance Plan, 36096IL0810138
-
Does Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, 36096IL0810138 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (36096IL0810138) Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs?
Does (36096IL0810138) Health Insurance Plan, Variant (36096IL0810138-01) have Out Of Country Coverage?
Does (36096IL0810138) Health Insurance Plan, Variant (36096IL0810138-01) have Out of Service Area Coverage?
Does (36096IL0810138) Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs?
Does Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs for Asthma?
Does Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs for Heart disease?
Does Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs for Depression?
Does Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs for Diabetes?
Does Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs for Low back pain?
Does Blue Precision Bronze HMO℠ 701 - Rx Copays Health Insurance Plan, Variant (36096IL0810138-01) offer Disease Management Programs 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