Blue Precision Gold HMO℠ 707 - 36096IL0810143 Health Insurance Plan

Blue Cross Blue Shield of Illinois health insurance plan with the Plan ID 36096IL0810143. The plan is called Blue Precision Gold HMO℠ 707.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 36096IL0810143
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 36096IL0810143-01
Provider Network(s) ['ILN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Jul 2024 06:14 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 - 36096IL0810143-00

Standard On Exchange Plan - 36096IL0810143-01

Open to Indians below 300% FPL - 36096IL0810143-02

Open to Indians above 300% FPL - 36096IL0810143-03

Last Plan Update Date Thu, 12 Jan 2023 00:00 GMT
Last Import Date Tue, 16 Jul 2024 06:14 GMT

Benefits of Blue Precision Gold HMO℠ 707 Health Insurance Plan, 36096IL0810143-01

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

25.00% Coinsurance after deductible

100.00%
Accidental Dental
YES

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

25.00% Coinsurance after deductible

100.00%
Bariatric Surgery
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Year

YES

25.00% Coinsurance after deductible

100.00%
Cosmetic Surgery

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

YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

No Charge

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
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

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
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

No Charge

100.00%
Gender Affirming Care
YES

25.00% Coinsurance after deductible

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

$15.00

100.00%
Habilitation Services

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

YES

$30.00

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

25.00% Coinsurance after deductible

100.00%
Home Health Care Services
YES

No Charge

100.00%
Hospice Services
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Infertility Treatment

Limit: 4.0 Procedure(s) per Benefit Period

4 completed oocyte retrievals per benefit period.

YES

25.00% Coinsurance after deductible

100.00%
Infusion Therapy

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

YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

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

$60.00

100.00%
Nutritional Counseling

Covered for Preventive and Diabetes services only.

YES

25.00% Coinsurance after deductible

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

$60.00

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

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services
YES

$30.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

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

$30.00

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

$30.00

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

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

$30.00

100.00%
Private-Duty Nursing

Exclusions: Inpatient excluded

YES

25.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

$30.00

100.00%
Rehabilitative Speech Therapy
YES

$30.00

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

Limit: 1.0 Visit(s) per Benefit Period

YES

25.00% Coinsurance after deductible

100.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care

Covered when medically necessary.

YES

25.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility
YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

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

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

100.00%
Transplant
YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$45.00

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

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

100.00%

Blue Precision Gold HMO℠ 707 Health Insurance Plan Variant 36096IL0810143-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.780017779
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 Standard Gold On Exchange Plan
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 0.998457631
First Tier Utilization 100%
Formulary ID ILF015
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 Gold
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) 36096IL0810143-01
Plan Marketing Name Blue Precision Gold HMO℠ 707
Plan Type HMO
Plan Variant Marketing Name Blue Precision Gold HMO℠ 707
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,600
SBC Scenario, Having a Baby, Copayment $40
SBC Scenario, Having a Baby, Deductible $2,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $100
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ILS032
Source Name SERFF
Specialist Requiring a Referral Referrals are required for some services. Please check with your Medical Group for details.
Plan ID 36096IL0810143
State Code IL
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, 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), Default Coinsurance 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $4000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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
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 Gold HMO℠ 707 Health Insurance Plan, 36096IL0810143

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

Frequently Asked Questions(FAQ) about Blue Precision Gold HMO℠ 707, 36096IL0810143 Health Insurance Plan, 36096IL0810143

  • Does Blue Precision Gold HMO℠ 707 Health Insurance Plan, 36096IL0810143 support Mail Ordering?

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

  • Does (36096IL0810143) Health Insurance Plan, Variant (36096IL0810143-01) 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 (36096IL0810143) Health Insurance Plan, Variant (36096IL0810143-01) 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 (36096IL0810143) Health Insurance Plan, Variant (36096IL0810143-01) have Out of Service Area Coverage?

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

    Does (36096IL0810143) Health Insurance Plan, Variant (36096IL0810143-01) 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 Gold HMO℠ 707 Health Insurance Plan, Variant (36096IL0810143-01) offer Disease Management Programs for Asthma?

    Yes, the Blue Precision Gold HMO℠ 707 Health Insurance Plan Variant 36096IL0810143-01 offers Disease Management Program for Asthma.

    Does Blue Precision Gold HMO℠ 707 Health Insurance Plan, Variant (36096IL0810143-01) offer Disease Management Programs for Heart disease?

    Yes, the Blue Precision Gold HMO℠ 707 Health Insurance Plan Variant 36096IL0810143-01 offers Disease Management Program for Heart disease.

    Does Blue Precision Gold HMO℠ 707 Health Insurance Plan, Variant (36096IL0810143-01) offer Disease Management Programs for Depression?

    Yes, the Blue Precision Gold HMO℠ 707 Health Insurance Plan Variant 36096IL0810143-01 offers Disease Management Program for Depression.

    Does Blue Precision Gold HMO℠ 707 Health Insurance Plan, Variant (36096IL0810143-01) offer Disease Management Programs for Diabetes?

    Yes, the Blue Precision Gold HMO℠ 707 Health Insurance Plan Variant 36096IL0810143-01 offers Disease Management Program for Diabetes.

    Does Blue Precision Gold HMO℠ 707 Health Insurance Plan, Variant (36096IL0810143-01) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue Precision Gold HMO℠ 707 Health Insurance Plan Variant 36096IL0810143-01 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue Precision Gold HMO℠ 707 Health Insurance Plan, Variant (36096IL0810143-01) offer Disease Management Programs for Low back pain?

    Yes, the Blue Precision Gold HMO℠ 707 Health Insurance Plan Variant 36096IL0810143-01 offers Disease Management Program for Low back pain.

    Does Blue Precision Gold HMO℠ 707 Health Insurance Plan, Variant (36096IL0810143-01) offer Disease Management Programs for Pregnancy?

    Yes, the Blue Precision Gold HMO℠ 707 Health Insurance Plan Variant 36096IL0810143-01 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 16 Jul 2024 06:14 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