Illinois health plan · 2025

Blue Choice Preferred Gold PPO℠ Standard - Rx Copays · 36096IL0990293

Blue Cross and Blue Shield of Illinois offers this marketplace health insurance plan (Plan ID 36096IL0990293) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Gold Plan type: PPO CSR: Limited Cost Sharing Plan Variation Issuer: Blue Cross and Blue Shield of Illinois
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 78.06% (21.94% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$609 – $2388

Before subsidies

Estimate after subsidies

Deductible

$1,500

$3000 per group

See deductible details

Max out-of-pocket

$7,800

$15600 per group

Review MOOP rules

Office visits

Primary care $30.00
Specialist $60.00
HSA Not eligible

Drug tiers

Generic $15.00
Preferred brand $30.00

View formulary tiers

$834 / mo before subsidies

≈ $10010 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$2643 / mo before subsidies

≈ $31721 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$3201 / mo before subsidies

≈ $38417 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$2035 / mo before subsidies

≈ $24414 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

25.00% Coinsurance after deductible

Durable Medical Equipment

25.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Illinois). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Limited Cost Sharing Plan Variation plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

25.00% Coinsurance after deductible

Durable Medical Equipment

25.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 36096IL0990293
Coverage year 2025
State Illinois
Issuer Blue Cross and Blue Shield of Illinois
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 36096IL0990293-03
Available variants

Standard Off Exchange Plan · 36096IL0990293-00

Standard On Exchange Plan · 36096IL0990293-01

Open to Indians below 300% FPL · 36096IL0990293-02

Open to Indians above 300% FPL · 36096IL0990293-03
Last plan update Mon, 28 Oct 2024 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in Illinois 76
PCPs in Illinois N/A
Telehealth support Data pending
Nationwide providers 336
76 doctors statewide

Provider network(s)

Providers Illinois All US states
All 76 336
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 44 217

Drug coverage overview

3,934 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
GENERIC 2,307
SPECIALTY 869
NON-PREFERRED-BRAND 758
Prior authorization Drugs
Required 915
Not Required 3,019
Step therapy Drugs
Required 0
Not Required 3,934
Quantity limits Drugs
Has Limit 1,649
No Limit 2,285

Customer highlights

What stands out for members

  • Issuer: Blue Cross and Blue Shield of Illinois · Plan ID 36096IL0990293 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 36096IL0990293-03 (Open to Indians above 300% FPL) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 25.0 Visit(s) per Year

nan

Exclusions: nan

Diabetes Education

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Home Health Care Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Laboratory Outpatient and Professional Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$60.00
Tier 1 in-network $60.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Preventive Care/Screening/Immunization

0.00%
Tier 1 in-network 0.00%
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$30.00
Tier 1 in-network $30.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$30.00
Tier 1 in-network $30.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Rehabilitative Speech Therapy

$30.00
Tier 1 in-network $30.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Specialist Visit

$60.00
Tier 1 in-network $60.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Urgent Care Centers or Facilities

$45.00
Tier 1 in-network $45.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

X-rays and Diagnostic Imaging

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network $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.

Exclusions: nan

Dialysis

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Durable Medical Equipment

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Emergency Room Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 25.00% Coinsurance after deductible

nan

Exclusions: nan

Emergency Transportation/Ambulance

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 25.00% Coinsurance after deductible

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.

Exclusions: Not covered under the hospice program.

Hospice Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network $2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible

nan

Exclusions: nan

Inpatient Physician and Surgical Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network $2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible

Member cost share may vary based on place of treatment

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$30.00
Tier 1 in-network $30.00
Out-of-network 50.00% Coinsurance after deductible

Member cost share may vary based on place of treatment

Exclusions: nan

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network $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.

Exclusions: nan

Outpatient Rehabilitation Services

$30.00
Tier 1 in-network $30.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Radiation

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Skilled Nursing Facility

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Substance Abuse Disorder Inpatient Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network $2000.00 Copay per Stay with deductible, 50.00% Coinsurance after deductible

Member cost share may vary based on place of treatment

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$30.00
Tier 1 in-network $30.00
Out-of-network 50.00% Coinsurance after deductible

Member cost share may vary based on place of treatment

Exclusions: nan

Transplant

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

One hearing aid per ear every 24 months when deemed medically necessary.

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

$30.00
Tier 1 in-network $30.00
Out-of-network 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.

Exclusions: nan

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Visit(s) per Year

When purchasing Out of Network, reimbursements are available. See benefit book for details.

Exclusions: nan

Well Baby Visits and Care

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$15.00
Tier 1 in-network $15.00
Out-of-network $15.00

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.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Non-Preferred Brand Drugs

$60.00
Tier 1 in-network $60.00
Out-of-network $60.00

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.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Preferred Brand Drugs

$30.00
Tier 1 in-network $30.00
Out-of-network $30.00

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.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Specialty Drugs

$250.00
Tier 1 in-network $250.00
Out-of-network $250.00

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.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

$100.00
Tier 1 in-network $100.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Member cost share may vary based on place of treatment

Exclusions: nan

Bariatric Surgery

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Cosmetic Surgery

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Only covered when medically necessary.

Exclusions: nan

Eye Glasses for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00% Coinsurance after deductible

Limit: 1.0 Item(s) per Year

All frames will first apply towards the allowance. Discount will apply on remaining balance, after the allowance. See benefit book for details

Exclusions: nan

Gender Affirming Care

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Habilitation Services

$30.00
Tier 1 in-network $30.00
Out-of-network 50.00% Coinsurance after deductible

Therapy Services - Speech, Occupational and Physical; coverage for services provided by a physician or therapist.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Exclusions: nan

Infertility Treatment

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 4.0 Procedure(s) per Benefit Period

4 completed oocyte retrievals per benefit period.

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: Inpatient excluded.

Reconstructive Surgery

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Eye Exam (Adult)

Coverage details pending

nan

Exclusions: nan

Routine Foot Care

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Covered when medically necessary.

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Variant attributes

Blue Choice Preferred Gold PPO℠ Standard - Rx Copays · Variant 36096IL0990293-03

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Limited Cost Sharing Plan Variation

HIOS Product ID

36096IL099

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

36096IL0990293-03

Plan Marketing Name

Blue Choice Preferred Gold PPO℠ Standard - Rx Copays

Plan Variant Marketing Name

Blue Choice Preferred Gold PPO℠ Standard - Rx Copays

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

36096

Issuer Marketplace Marketing Name

Blue Cross and Blue Shield of Illinois

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

ILN009

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

Emergency and Urgent Care services. Non-emergency services received outside the service area may be covered with an approved waiver from the Plan.

Service Area ID

ILS139

State Code

IL

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.780612576352931

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$0

SBC Scenario, Having a Baby, Deductible

$0

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$0

SBC Scenario, Having Diabetes, Deductible

$0

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$0

SBC Scenario, Treatment of a Simple Fracture, Deductible

$0

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual

Not Applicable

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

25.00%

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$15600 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$7800 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$7,800

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

Not Applicable

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

ILF025

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

No

Design Type

Design 1

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

EHB Percent of Total Premium

0.999062167595661

First Tier Utilization

100%

Import Date

2024-10-28 20:01:45

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

PPO

QHP/Non QHP

Both

Source Name

SERFF

Plan ID

36096IL0990293

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group

$3000 per group

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person

$1500 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$1,500

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group

$45000 per group

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person

$15000 per person

Combined Medical and Drug EHB Deductible, Out of Network, Individual

$15,000

Unique Plan Design

No

Wellness Program Offered

No

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Illinois?

Blue Choice Preferred Gold PPO℠ Standard - Rx Copays (36096IL0990293) is a Gold PPO from Blue Cross and Blue Shield of Illinois in Illinois for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Blue Choice Preferred Gold PPO℠ Standard - Rx Copays support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Blue Choice Preferred Gold PPO℠ Standard - Rx Copays HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Child.

Does Blue Choice Preferred Gold PPO℠ Standard - Rx Copays support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with Blue Choice Preferred Gold PPO℠ Standard - Rx Copays?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy.

Is there out-of-country coverage for Blue Choice Preferred Gold PPO℠ Standard - Rx Copays?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: 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.

Does Blue Choice Preferred Gold PPO℠ Standard - Rx Copays cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Emergency and Urgent Care services. Non-emergency services received outside the service area may be covered with an approved waiver from the Plan.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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