8 / 20
{5}
Blue Cross Blue Shield of Illinois - Plan Design
In-Network
Out-of-Network
Deductible
(Individual / Family)
$1,500 / $4,500
$3,000 / $9,000
Coinsurance
80%
60%
Out-of-Pocket Maximum
(Individual / Family)
$3,500 / $10,200
$7,000 / $20,400
Office Visit Co-Pay
(Primary Care Physi-
cian / Specialist)
$30 / $50
60%
After Deductible
Preventive Care
100%
60%
After Deductible
Inpatient Hospital
80%
After Deductible
Deductible;
$300 Co-Pay & 40%
Outpatient Surgery
80%
After Deductible
60%
After Deductible
Lab, X-Ray (Outpatient)
80%
After Deductible
60%
After Deductible
Major Diagnostics
(CT, PET, MRI, MRA, &
Nuclear Medicine)
80%
After Deductible
60%
After Deductible
Emergency Room
$150 Co-Pay
$150 Co-Pay
Urgent Care
80%
After Deductible
60%
After Deductible
Prescription Drug
Retail
Mail Order (90-Day
Supply)
Separate Out of Pocket
Maximum
Features
Preferred Pharmacy
$10/$40/$60
2 x Retail
$1,000 Individual
$3,000 Family
Non-Preferred Pharmacy
$15/$50/$70
Out of Network
$15/$50/$70/ +25%