Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays - 36096IL0990297 Health Insurance Plan
Blue Cross Blue Shield of Illinois health insurance plan with the Plan ID 36096IL0990297. The plan is called Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 36096IL0990297 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Illinois | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 36096IL0990297-02 | ||||||||||||||||||
| Provider Network(s) | PREFERRED BLUE-CHOICE-PREFERRED-PPO NON-PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 36096IL0990297-00 Standard On Exchange Plan - 36096IL0990297-01 Open to Indians below 300% FPL - 36096IL0990297-02 Open to Indians above 300% FPL - 36096IL0990297-03 73% AV Silver Plan - 36096IL0990297-04 |
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| Last Plan Update Date | Mon, 28 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, 36096IL0990297-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Accidental Dental
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan Member cost share may vary based on place of treatment |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Bariatric Surgery
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Year Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Cosmetic Surgery
Exclusions: nan Only covered when medically necessary. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dialysis
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Exclusions: 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. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan All frames will first apply towards the allowance. Discount will apply on remaining balance, after the allowance. See benefit book for details |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Generic Drugs
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. 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. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Habilitation Services
Exclusions: nan Therapy Services - Speech, Occupational and Physical; coverage for services provided by a physician or therapist. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hearing Aids
Exclusions: nan One hearing aid per ear every 24 months when deemed medically necessary. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Home Health Care Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hospice Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Infertility Treatment
Limit: 4.0 Procedure(s) per Benefit Period Exclusions: nan 4 completed oocyte retrievals per benefit period. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Infusion Therapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan Member cost share may vary based on place of treatment |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Member cost share may vary based on place of treatment |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Non-Preferred Brand Drugs
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. 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. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Rehabilitation Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preferred Brand Drugs
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. 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. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Prenatal and Postnatal Care
Exclusions: nan First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Private-Duty Nursing
Exclusions: Inpatient excluded. nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Prosthetic Devices
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Radiation
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Reconstructive Surgery
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Speech Therapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Exclusions: nan When purchasing Out of Network, reimbursements are available. See benefit book for details. |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
Exclusions: nan Covered when medically necessary. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Skilled Nursing Facility
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialty Drugs
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. 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. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan Member cost share may vary based on place of treatment |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan Member cost share may vary based on place of treatment |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Transplant
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan Variant 36096IL0990297-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Zero Cost Sharing Plan Variation |
| 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 | 0.998949158514321 |
| First Tier Utilization | 100% |
| Formulary ID | ILF026 |
| Formulary URL | URL |
| HIOS Product ID | 36096IL099 |
| Import Date | 2024-10-28 20:01:45 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 36096 |
| Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of Illinois |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| 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. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 36096IL0990297-02 |
| Plan Marketing Name | Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS059 |
| Source Name | SERFF |
| Plan ID | 36096IL0990297 |
| State Code | IL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, 36096IL0990297
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays, 36096IL0990297 Health Insurance Plan, 36096IL0990297
-
Does Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, 36096IL0990297 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (36096IL0990297) Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs?
Does (36096IL0990297) Health Insurance Plan, Variant (36096IL0990297-02) have Out Of Country Coverage?
Does (36096IL0990297) Health Insurance Plan, Variant (36096IL0990297-02) have Out of Service Area Coverage?
Does (36096IL0990297) Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs?
Does Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs for Asthma?
Does Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs for Heart disease?
Does Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs for Depression?
Does Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs for Diabetes?
Does Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs for Low back pain?
Does Blue Choice Preferred Silver PPO℠ Standard - Select Rx Copays Health Insurance Plan, Variant (36096IL0990297-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API