Blue Precision Bronze HMO℠ 708 - 36096IL0810175 Health Insurance Plan

Blue Cross Blue Shield of Illinois health insurance plan with the Plan ID 36096IL0810175. The plan is called Blue Precision Bronze HMO℠ 708.

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 36096IL0810175
Health Insurance Plan Year 2023
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 36096IL0810175-02
Provider Network(s) ['ILN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Jul 2024 06:37 GMT).

Providers Illinois All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 36096IL0810175-00

Standard On Exchange Plan - 36096IL0810175-01

Open to Indians below 300% FPL - 36096IL0810175-02

Open to Indians above 300% FPL - 36096IL0810175-03

Last Plan Update Date Thu, 12 Jan 2023 00:00 GMT
Last Import Date Tue, 23 Jul 2024 06:37 GMT

Benefits of Blue Precision Bronze HMO℠ 708 Health Insurance Plan, 36096IL0810175-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

$0.00, 0.00%

100.00%
Accidental Dental
YES

$0.00, 0.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00, 0.00%

100.00%
Bariatric Surgery
YES

$0.00, 0.00%

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

$0.00, 0.00%

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Cosmetic Surgery

Covered only for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases.

YES

$0.00, 0.00%

100.00%
Delivery and All Inpatient Services for Maternity Care

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%

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

$0.00, 0.00%

100.00%
Dialysis
YES

$0.00, 0.00%

100.00%
Durable Medical Equipment
YES

$0.00, 0.00%

100.00%
Emergency Room Services
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

Provider-designated frames are covered. An allowance may apply to non-provider-designated frames. Coinsurance may apply to non-provider-designated frames on the remaining balance over the allowance. See benefit book for details.

YES

$0.00, 0.00%

100.00%
Gender Affirming Care
YES

$0.00, 0.00%

100.00%
Generic Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, 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. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details.

YES

$0.00, 0.00%

100.00%
Habilitation Services

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

YES

$0.00, 0.00%

100.00%
Hearing Aids

1 hearing aid per ear every 24 months under 19 and 19 and over they get $2500 per ear every 24 months.

YES

$0.00, 0.00%

100.00%
Home Health Care Services
YES

$0.00, 0.00%

100.00%
Hospice Services
YES

$0.00, 0.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$0.00, 0.00%

100.00%
Infertility Treatment

Limit: 4.0 Procedure(s) per Benefit Period

4 completed oocyte retrievals per benefit period.

YES

$0.00, 0.00%

100.00%
Infusion Therapy

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

YES

$0.00, 0.00%

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$0.00, 0.00%

100.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$0.00, 0.00%

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00, 0.00%

100.00%
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, OTC Equivalents and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Out of Network Pharmacy coverage is only available in emergency situations. 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%

100.00%
Nutritional Counseling

Covered for Preventive and Diabetes services only.

YES

$0.00, 0.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$0.00, 0.00%

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$0.00, 0.00%

100.00%
Outpatient Rehabilitation Services
YES

$0.00, 0.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

100.00%
Preferred Brand Drugs

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

Out of Network Pharmacy coverage is only available in emergency situations. 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%

100.00%
Prenatal and Postnatal Care

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%

100.00%
Preventive Care/Screening/Immunization
YES

$0.00, 0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$0.00, 0.00%

100.00%
Private-Duty Nursing

Exclusions: Inpatient excluded

YES

$0.00, 0.00%

100.00%
Prosthetic Devices
YES

$0.00, 0.00%

100.00%
Radiation
YES

$0.00, 0.00%

100.00%
Reconstructive Surgery
YES

$0.00, 0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$0.00, 0.00%

100.00%
Rehabilitative Speech Therapy
YES

$0.00, 0.00%

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)

Limit: 1.0 Visit(s) per Benefit Period

YES

$0.00, 0.00%

100.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Routine Foot Care

Covered when medically necessary.

YES

$0.00, 0.00%

100.00%
Skilled Nursing Facility
YES

$0.00, 0.00%

100.00%
Specialist Visit
YES

$0.00, 0.00%

100.00%
Specialty Drugs

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, 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. Out of Network Pharmacy coverage is only available in emergency situations. 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%

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00, 0.00%

100.00%
Transplant
YES

$0.00, 0.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$0.00, 0.00%

100.00%
Urgent Care Centers or Facilities
YES

$0.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

100.00%

Blue Precision Bronze HMO℠ 708 Health Insurance Plan Variant 36096IL0810175-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
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, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 0.9979551
First Tier Utilization 100%
Formulary ID ILF019
Formulary URL URL
HIOS Product ID 36096IL081
Import Date 1/12/2023 20:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
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 Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID ILN002
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 Coverage outside our service area is available for Emergency and Urgent Care services only.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 36096IL0810175-02
Plan Marketing Name Blue Precision Bronze HMO℠ 708
Plan Type HMO
Plan Variant Marketing Name Blue Precision Bronze HMO℠ 708
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 ILS042
Source Name SERFF
Specialist Requiring a Referral Referrals are required for some services. Please check with your Medical Group for details.
Plan ID 36096IL0810175
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 Precision Bronze HMO℠ 708 Health Insurance Plan, 36096IL0810175

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue Precision Bronze HMO℠ 708, 36096IL0810175 Health Insurance Plan, 36096IL0810175

  • Does Blue Precision Bronze HMO℠ 708 Health Insurance Plan, 36096IL0810175 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (36096IL0810175) Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (36096IL0810175) Health Insurance Plan, Variant (36096IL0810175-02) have Out Of Country Coverage?

    Yes. 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 (36096IL0810175) Health Insurance Plan, Variant (36096IL0810175-02) have Out of Service Area Coverage?

    Yes. Details: Coverage outside our service area is available for Emergency and Urgent Care services only.

    Does (36096IL0810175) Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Blue Precision Bronze HMO℠ 708 Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs for Asthma?

    Yes, the Blue Precision Bronze HMO℠ 708 Health Insurance Plan Variant 36096IL0810175-02 offers Disease Management Program for Asthma.

    Does Blue Precision Bronze HMO℠ 708 Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs for Heart disease?

    Yes, the Blue Precision Bronze HMO℠ 708 Health Insurance Plan Variant 36096IL0810175-02 offers Disease Management Program for Heart disease.

    Does Blue Precision Bronze HMO℠ 708 Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs for Depression?

    Yes, the Blue Precision Bronze HMO℠ 708 Health Insurance Plan Variant 36096IL0810175-02 offers Disease Management Program for Depression.

    Does Blue Precision Bronze HMO℠ 708 Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs for Diabetes?

    Yes, the Blue Precision Bronze HMO℠ 708 Health Insurance Plan Variant 36096IL0810175-02 offers Disease Management Program for Diabetes.

    Does Blue Precision Bronze HMO℠ 708 Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Precision Bronze HMO℠ 708 Health Insurance Plan Variant 36096IL0810175-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Precision Bronze HMO℠ 708 Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs for Low back pain?

    Yes, the Blue Precision Bronze HMO℠ 708 Health Insurance Plan Variant 36096IL0810175-02 offers Disease Management Program for Low back pain.

    Does Blue Precision Bronze HMO℠ 708 Health Insurance Plan, Variant (36096IL0810175-02) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Precision Bronze HMO℠ 708 Health Insurance Plan Variant 36096IL0810175-02 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 23 Jul 2024 06:37 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