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Blue PPO Silver Plan 003
Our Rating:
Benefit Highlight
Blue PPO Silver 003
Plan Features
Lifetime Maximum
Unlimited
Participating providers
PPO Network
90% of IL doctors; over 200 IL hospitals
90% of IL doctors; over 200 IL hospitals
Individual Deductible
$6,000
Family Deductible
$12,700
Coinsurance
100%
Out of Pocket Maximum
Includes deductible
Includes deductible
$6,000
Family Out of Pocket Maximum
Includes deductible
Includes deductible
$12,700
Office Visit Copay (Primary Care/Specialist)
$30 / $50 specialist
Medical Coverage Details
Inpatient Hospital Medical / Surgical Services
Hospital Services and Hospital Diagnostic Testing
Hospital Services and Hospital Diagnostic Testing
$250 copay then 100% after deductible
Outpatient Surgery
$200 copay then 100% after deductible
Emergency Room / Outpatient Emergency Care
Physician and Hospital
Physician and Hospital
$500 copay then 100% after deductible
Outpatient Hospital Diagnostic Testing
100% after deductible
Mental Illness & Substance Abuse Rehab
(Outpatient Hospital/ Physician Care)
(Outpatient Hospital/ Physician Care)
$30 copay
Mental Illness & Substance Abuse Treatment
(Inpatient Hospital Care)
(Inpatient Hospital Care)
$250 copay then 100% coinsurance after deductible
Mental Illness & Substance Abuse Treatment
(Inpatient Physician Care)
(Inpatient Physician Care)
100% after deductible
Preventive Care
Covered at 100%, no copay
Maternity Coverage
$250 copay then 100% after deductible
Prescription Drugs
Preferred Generics
$0 copay
Non Preferred Generics
$10 copay
Preferred Formulary
$50 copay
Non-Preferred Formulary
$100 copay
Specialty
$150 copay
Prescription Drug Formulary
Standard
Cost Reductions
Tax Credit Eligible
Yes
Cost Sharing Eligible
No
HSA Eligibile
No
Blue PPO Silver Plan 004
Our Rating:
Benefit Highlight
Blue PPO Silver 004
Plan Features
Lifetime Maximum
Unlimited
Participating providers
PPO Network
90% of IL doctors; over 200 IL hospitals
90% of IL doctors; over 200 IL hospitals
Individual Deductible
$3,000
Family Deductible
$9,000
Coinsurance
80%
Out of Pocket Maximum
Includes deductible
Includes deductible
$6,350
Family Out of Pocket Maximum
Includes deductible
Includes deductible
$12,700
Office Visit Copay (Primary Care/Specialist)
$30 / $50 specialist
Medical Coverage Details
Outpatient Surgery
$200 copay then 80% after deductible
Inpatient Hospital Medical / Surgical Services
Hospital Services and Hospital Diagnostic Testing
Hospital Services and Hospital Diagnostic Testing
$250 copay then 80% after deductible
Emergency Room / Outpatient Emergency Care
Physician and Hospital
Physician and Hospital
$500 copay then 80% after deductible
Outpatient Hospital Diagnostic Testing
80% after deductible
Mental Illness & Substance Abuse Rehab
(Outpatient Hospital/ Physcian Care)
(Outpatient Hospital/ Physcian Care)
$30 copay
Mental Illness & Substance Abuse Treatment
(Inpatient Hospital Care)
(Inpatient Hospital Care)
$250 copay then 80% coinsurance after deductible
Mental Illness & Substance Abuse Treatment
(Inpatient Physician Care)
(Inpatient Physician Care)
80% coinsurance after deductible
Preventive Care
Covered at 100%, no copay
Maternity Coverage
$200 copay then 80% after deductible
Prescription Drugs
Preferred Generics
$0 copay
Non Preferred Generics
$10 copay
Preferred Formulary
$50 copay
Non-Preferred Formulary
$100 copay
Specialty
$150 copay
Prescription Drug Formulary
Standard
Cost Reductions
Tax Credit Eligible
Yes
Cost Sharing Eligible
No
HSA Eligibile
No