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Blue Choice Preferred Bronze PPO℠ 701

36096IL0990275
Bronze
PPO

Blue Choice Preferred Bronze PPO℠ 701 is a Bronze PPO plan by Blue Cross and Blue Shield of Illinois.

IMPORTANT: You are viewing the 2023 version of Blue Choice Preferred Bronze PPO℠ 701 36096IL0990275. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Blue Choice Preferred Bronze PPO℠ 701 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Blue Choice Preferred Bronze PPO℠ 701 36096IL0990275.
Insurer: Blue Cross and Blue Shield of Illinois
Network Type: PPO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 36096IL0990275

Cost-Sharing Overview

Blue Choice Preferred Bronze PPO℠ 701 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Choice Preferred Bronze PPO℠ 701?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Blue Choice Preferred Bronze PPO℠ 701 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue Choice Preferred Bronze PPO℠ 701 covers when you are out of the service area or out of the country.

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.
National Network: Yes

Additional Benefits and Cost-Sharing

Blue Choice Preferred Bronze PPO℠ 701 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Specialist Visit
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$600.00 Copay with deductible 40.00% Coinsurance after deductible$2000.00 Copay with deductible 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. 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.
Outpatient Surgery Physician/Surgical Services
Covered
$200.00 Copay with deductible 50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hospice Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible4 Procedure(s) per Benefit Period 4 completed oocyte retrievals per benefit period.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Inpatient excluded
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 50.00% Coinsurance after deductible
Home Health Care Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible 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.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$850.00 Copay per Stay with deductible 50.00% Coinsurance after deductible$2000.00 Copay per Stay with deductible 50.00% Coinsurance after deductible 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.
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Cosmetic Surgery
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Covered only for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases.
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Prenatal and Postnatal Care
Covered
No Charge after deductible 50.00% Coinsurance after deductible First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.
Delivery and All Inpatient Services for Maternity Care
Covered
$850.00 Copay with deductible 50.00% Coinsurance after deductible$2000.00 Copay with deductible 50.00% Coinsurance after deductible 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.
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
$850.00 Copay per Stay with deductible 50.00% Coinsurance after deductible$2000.00 Copay per Stay with deductible 50.00% Coinsurance after deductible 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.
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
$850.00 Copay per Stay with deductible 50.00% Coinsurance after deductible$2000.00 Copay per Stay with deductible 50.00% Coinsurance after deductible 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.
Generic Drugs
Covered
$23.00 $33.00 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.
Preferred Brand Drugs
Covered
No Charge after deductible No Charge after deductible 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.
Non-Preferred Brand Drugs
Covered
No Charge after deductible No Charge after deductible 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.
Specialty Drugs
Covered
No Charge after deductible No Charge after deductible 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.
Outpatient Rehabilitation Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Habilitation Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Therapy Services – Speech, Occupational and Physical; coverage for services provided by a physician or therapist.
Chiropractic Care
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible25 Visit(s) per Year
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hearing Aids
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible 1 hearing aid per ear every 24 months under 19 and 19 and over they get $2500 per ear every 24 months.
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Preventive Care/Screening/Immunization
Covered
No Charge 50.00% Coinsurance after deductible
Routine Foot Care
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Covered when medically necessary.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(s) per Year When purchasing Out of Network, reimbursements are available. See benefit book for details.
Eye Glasses for Children
Covered
No Charge 100.00%1 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.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Well Baby Visits and Care
Covered
No Charge 50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Transplant
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Accidental Dental
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Dialysis
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Chemotherapy
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Radiation
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Education
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Infusion Therapy
Covered
$100.00 50.00% Coinsurance after deductible Member cost share may increase when using a Hospital based facility for these services. See benefit booklet for details.
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Nutritional Counseling
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Covered for Preventive and Diabetes services only.
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Gender Affirming Care
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue Choice Preferred Bronze PPO℠ 701 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Blue Choice Preferred Bronze PPO℠ 701 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Blue Choice Preferred Bronze PPO℠ 701?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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