Blue Cross Blue Shield Blue Choice Silver PPO 004 (Illinois)

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Company Blue Cross Blue Shield of Illinois
Plan Year 2014
State Illinois
Metal Tier Silver
Plan Type PPO
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Cost Sharing Benefits (In Network)

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.

Deductible (Individual) $3,000
Deductible (Family) $9,000
Coinsurance 20%
Out of Pocket Maximum (Individual) $6,350
Out of Pocket Maximum (Family) $12,700

Doctors Visits

Primary Care Visit $35
Specialist Visit $55
In Patient Hospital Services $250 Copay per Stay and 20% Coin
Emergency Room Services $500 Copay and 20% Coinsurance a

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 20% coinsurance
Laboratory Outpatient and Professional Services 20% coinsurance
X-ray and Diagnostic Imaging 20% coinsurance

Other

Mental / Behavioral Health 20% coinsurance
Rehabilitative Speech Therapy 20% coinsurance
Rehabilitative Occupational & Physical Therapy 20% coinsurance
Outpatient Facility 200 deductible per visit, 0.2
Outpatient Surgery 20% coinsurance

Prescription Drugs

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. To understand how cost sharing reductions work and how they work for you see our article about Obamacare Cost Sharing Reduction Discounts

Deductibles and Cost Sharing

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
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 PPO Gold 001
Blue PPO Gold 002
Blue PPO Silver 003
Blue PPO Silver 004
Blue PPO Bronze 005
Blue PPO Bronze 006
Blue Security PPO 010
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 Cross Blue Shield Basic 5, a Multi-State Plan
Blue Choice Gold PPO 001
Blue Choice Gold PPO 002
Blue Choice Silver PPO 003
Blue Choice Silver PPO 004
Blue Choice Bronze PPO 005
Blue Choice Bronze PPO 006
Blue Choice Security PPO 008
Blue Choice Gold PPO 001
Blue Choice Gold PPO 001
Blue Choice Gold PPO 001
Blue Choice Gold PPO 001
Blue Choice Gold PPO 002
Blue Choice Gold PPO 002
Blue Choice Gold PPO 002
Blue Choice Gold PPO 002
Blue Choice Silver PPO 003
Blue Choice Silver PPO 003
Blue Choice Silver PPO 003
Blue Choice Silver PPO 003
Blue Choice Silver PPO 004
Blue Choice Silver PPO 004
Blue Choice Silver PPO 004
Blue Choice Silver PPO 004
Blue Choice Bronze PPO 005
Blue Choice Bronze PPO 005
Blue Choice Bronze PPO 005
Blue Choice Bronze PPO 005
Blue Choice Bronze PPO 006
Blue Choice Bronze PPO 006
Blue Choice Bronze PPO 006
Blue Choice Bronze PPO 006
Blue Choice Security PPO 008
Blue Choice Security PPO 008
Blue Choice Security PPO 008
Blue Choice Security PPO 008
Blue Precision Gold HMO 001
Blue Precision Silver HMO 002
Blue Precision Bronze HMO 003
Blue Precision Gold HMO 001
Blue Precision Gold HMO 001
Blue Precision Gold HMO 001
Blue Precision Gold HMO 001
Blue Precision Gold HMO 001
Blue Precision Silver HMO 002
Blue Precision Silver HMO 002
Blue Precision Silver HMO 002
Blue Precision Silver HMO 002
Blue Precision Silver HMO 002
Blue Precision Bronze HMO 003
Blue Precision Bronze HMO 003
Blue Precision Bronze HMO 003
Blue Precision Bronze HMO 003
Blue Precision Bronze HMO 003

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