Form 228342.0816 - Individual Plan Comparison Chart

2017

All Blue Cross and Blue Shield of Illinois (BCBSIL) plans provide coverage

Individual Plan Comparison Chart

for preventive services and maternity care. Please see your Summary of

Benefits and Coverage or visit for more specific information.

Participating Provider Coverage Shown

Platinum

Blue Precision Platinum HMO

104

Individual Deductible

$250

Coinsurance

10%

Out-of-Pocket Maximum (includes deductible)

$3,000

Primary Care Office Visit

$25

Specialist Office Visit

$55

Mental Illness Treatment and Substance Abuse Rehab Office Visit

Emergency Room

$600 per occurrence copay, then 10%

Urgent Care

$55

Inpatient Hospital Services

$400 per occurrence copay, then 10%

Outpatient Surgery

$200 per occurrence copay, then 30%

Outpatient X-Rays and Diagnostic Imaging

Outpatient Imaging (CT/PET Scans/MRIs)

Network

Blue Precision HMO

HSA Eligible

Outpatient Prescription Drugs - Preferred Pharmacy

$0/$10/$50/$100/30%

6 7

Outpatient Prescription Drugs - Non-Preferred Pharmacy

$0/$10/$50/$100/30%

6 7

Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider.

Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost.

Prior-Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from

Prescription Drug Utilization Benefit Management Programs

BCBSIL and you may first need to try more clinically appropriate or cost-effective drugs.

Mail-Order Program: You may receive up to a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on

your prescription drug benefit.

Benefits reduced when non-participating providers are used. This is a summary of benefit highlights only. All benefits shown indicate member responsibility.

As a reminder, a Health Savings Account (HSA) has tax and legal ramifications. Blue Cross and Blue Shield of Illinois does not provide legal or tax advice and nothing

The standard deductible and out-of-pocket maximum for this plan are shown. You must pay all the costs up to the deductible amount before this plan begins to pay for

herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be

covered services you use.

used or relied on for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the

transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax adviser regarding tax

Annual deductible and, if applicable, coinsurance still apply.

consequences of specific health insurance plans or products.

Members may have lower out-of-pocket costs for services provided by freestanding outpatient facilities than the out-of-pocket costs for services provided in a hospital

Prescription benefit coverage starts after annual medical deductible has been met.

setting. See benefit booklet for additional details.

Preferred Generics / Non-Preferred Generics / Preferred Brand / Non-Preferred Brand / Specialty

Specialty tier is limited to a 30-day supply. Coverage limitations may apply to certain medications.

* This plan is not available on Get Covered Illinois

, the Official Health Marketplace.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

228342.0816