Blue Cross Blue Shield Blue Choice Silver PPO 004 IL

Plan Information
Company Blue Cross Blue Shield of Illinois
State IL
Metal Tier Silver
Plan Type PPO

Cost Sharing Benefits

These details are for the standard Silver plan. For reduced Cost Sharing versions scroll down below

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $3,000 $6,000
Deductible (Family) $9,000 $18,000
Coinsurance 20% 40%
Out of Pocket Maximum (Individual) $6,350 $12,700
Out of Pocket Maximum (Family) $12,700 $25,400
Services In Network Out of Network
Primary Care Visit $35 40% coinsurance
Specialist Visit $55 40% coinsurance
In Patient Hospital Services $250 Copay per Stay and 20% Coin 40% coinsurance
Emergency Room Services $500 Copay and 20% Coinsurance a 500 deductible per visit, 0.2
Mental / Behavioral Health 20% coinsurance 40% coinsurance
Imaging (CT/PET Scans, MRIs) 20% coinsurance 40% coinsurance
Rehabilitative Speech Therapy 20% coinsurance 40% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance 40% coinsurance
Preventative Care $0 40% coinsurance
Laboratory Outpatient and Professional Services 20% coinsurance 40% coinsurance
X-ray and Diagnostic Imaging 20% coinsurance 40% coinsurance
Prescription Drugs In Network Out of Network
Generic Rx No Charge
Preferred Brand Rx $50
Non Preferred Brand Rx $100
Specialty Drugs $150

73% Cost Sharing Benefits

Households with incomes between 200% to 250% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $2,500.00
Deductible (Family) $7,500.00
Out of Pocket Maximum (Individual) $5,200.00
Out of Pocket Maximum (Family) $10,400.00
Services In Network Out of Network
Primary Care Physician $35
Specialists $55
Emergency Room $500 Copay and 20% Coinsurance a
Inpatient Facility $250 Copay per Stay and 20% Coin
Inpatient Physician 20% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx No Charge
Preferred Brand Rx $50
Non Preferred Brand Rx $100
Specialty Drugs $150

87% Cost Sharing Benefits

Households with incomes between 150% to 200% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $500.00
Deductible (Family) $1,500.00
Out of Pocket Maximum (Individual) $1,500.00
Out of Pocket Maximum (Family) $4,500.00
Services In Network Out of Network
Primary Care Physician $35
Specialists $55
Emergency Room $500 Copay and 20% Coinsurance a
Inpatient Facility $250 Copay per Stay and 20% Coin
Inpatient Physician 20% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx No Charge
Preferred Brand Rx $50
Non Preferred Brand Rx $100
Specialty Drugs $150

94% Cost Sharing Benefits

Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0.00
Deductible (Family) $0.00
Out of Pocket Maximum (Individual) $500.00
Out of Pocket Maximum (Family) $1,500.00
Services In Network Out of Network
Primary Care Physician $35
Specialists $55
Emergency Room $500 Copay and 20% Coinsurance a
Inpatient Facility $250 Copay per Stay and 20% Coin
Inpatient Physician 20% Coinsurance after deductible
Prescription Drugs In Network Out of Network
Generic Rx No Charge
Preferred Brand Rx $50
Non Preferred Brand Rx $100
Specialty Drugs $150

Other Plans

Other plans that are available in the state.

Plan Name
Blue Choice Bronze PPO 005
Blue Choice Bronze PPO 006
Blue Choice Gold PPO 001
Blue Choice Gold PPO 002
Blue Choice Silver PPO 003
Blue Choice Silver PPO 004
Blue Cross Blue Shield Basic 5, a Multi-State Plan
Blue Cross Blue Shield Premier 1, a Multi-State Plan
Blue Cross Blue Shield Premier 2, a Multi-State Plan
Blue Cross Blue Shield Solution 3, a Multi-State Plan
Blue Cross Blue Shield Solution 4, a Multi-State Plan
Blue PPO Bronze 005
Blue PPO Bronze 006
Blue PPO Gold 001
Blue PPO Gold 002
Blue PPO Silver 003
Blue PPO Silver 004
Blue Precision Bronze HMO 003
Blue Precision Gold HMO 001
Blue Precision Silver HMO 002
Blue Security PPO 010
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