Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023 – 12/31/2023
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross
and Blue Shield Association
SBC-IL-HMO-IND-2023 Page 1 of 6
: Blue Precision Silver HMO
SM
704 – Rx Copays
Coverage for: Individual/Family | Plan Type: HMO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsil.com/bb/ind/bb-
shsa33baviilp-il-2023.pdf or by calling 1-800-892-2803. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,
deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
Individual: Participating $7,500
Family: Participating $15,000
Generally, you must pay all of the costs from providers up to the deductible amount before this plan
begins to pay. If you have other family members on the plan, each family member must meet their
own individual deductible until the total amount of deductible expenses paid by all family members
meets the overall family deductible.
Are there services covered
before you meet your
deductible?
Yes. In-Network Preventive Health Care
services, some services with a
copayment, and some prescription drugs
are covered before you meet your
deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a
copayment or coinsurance may apply. For example, this plan covers certain preventive services
without cost sharing and before you meet your deductible. See a list of covered preventive services
at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles
for specific services?
No.
You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
Individual: Participating $9,100
Family: Participating $18,200
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other
family members in this plan, they have to meet their own out-of-pocket limits until the overall family
out-of-pocket limit must be met.
What is not included in
the out-of-pocket limit?
Premiums, balance billing charges, and
health care this plan doesn't cover.
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Will you pay less if you use
a network provider?
Yes. See www.bcbsil.com or call 1-800-
892-2803 for a list of Participating
Providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You
will pay the most if you use an out-of-network provider, and you might receive a bill from a provider
for the difference between the provider’s charge and what your plan pays (balance billing). Be
aware your network provider might use an out-of-network provider for some services (such as lab
work). Check with your provider before you get services.
Do you need a referral to
see a specialist?
Yes.
This plan will pay some or all of the costs to see a specialist for covered services but only if you
have a referral before you see the specialist.
Page 2 of 6
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross
and Blue Shield Association
SBC-IL-HMO-IND-2023
*For more information about limitations and exceptions, see the plan or policy document at www.bcbsil.com/bb/ind/bb-shsa33baviilp-il-2023.pdf.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Participating Provider
(You will pay the least)
Non-Participating Provider
(You will pay the most)
If you visit a health care
provider’s office or
clinic
Primary care visit to treat an
injury or illness
$70/visit; deductible does not apply
Not Covered
None
Specialist visit
$95/visit; deductible does not apply
Not Covered
Referral required.
Preventive care/screening/
immunization
No Charge; deductible does not apply
Not Covered
You may have to pay for services that
aren't preventive. Ask your provider if the
services needed are preventive. Then
check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood
work)
$90/test; deductible does not apply
Not Covered
Referral required.
Imaging (CT/PET scans,
MRIs)
$250/test; deductible does not apply
Not Covered
Referral required.
Page 3 of 6
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross
and Blue Shield Association
SBC-IL-HMO-IND-2023
*For more information about limitations and exceptions, see the plan or policy document at www.bcbsil.com/bb/ind/bb-shsa33baviilp-il-2023.pdf.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Participating Provider
(You will pay the least)
Non-Participating Provider
(You will pay the most)
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available at
www.bcbsil.com/rx23h/6T
Preferred generic drugs
Retail - $25/prescription
Mail - $75/prescription; deductible
does not apply
Not Covered
Limited to a 30-day supply at retail (or a 90-
day supply at a network of select retail
pharmacies). Up to a 90-day supply at mail
order. Specialty drugs limited to a 30-day
supply. Payment of the difference between
the cost of a brand name drug and a
generic may also be required if a generic
drug is available. Any differences between
the cost of the generic drug and the cost of
the brand name drug will apply to the
deductible or out-of-pocket maximum. The
applicable cost sharing (by tier) and the
cost difference between the generic and
brand will never exceed the overall cost of
the drug. The amount you may pay per 30-
day supply of a covered insulin drug,
regardless of quantity or type, shall not
exceed $100, when obtained from a
Participating Pharmacy.
Non-preferred generic
drugs
Retail - $70/prescription
Mail - $210/prescription; deductible
does not apply
Not Covered
Preferred brand drugs
Retail - $85/prescription
Mail - $255/prescription; deductible
does not apply
Not Covered
Non-preferred brand drugs
Retail - $120/prescription
Mail - $360/prescription; deductible
does not apply
Not Covered
Preferred specialty drugs
$250/prescription; deductible does not
apply
Not Covered
Non-preferred specialty
drugs
$500/prescription; deductible does not
apply
Not Covered
If you have outpatient
surgery
Facility fee (e.g.,
ambulatory surgery center)
$350/visit plus 50% coinsurance
Not Covered
Referral required.
For Outpatient Infusion Therapy, see your
benefit booklet* for details.
Physician/surgeon fees
$90/visit; deductible does not apply
Not Covered
If you need immediate
medical attention
Emergency room care
$1,200/visit plus 50% coinsurance
$1,200/visit plus 50% coinsurance
Per occurrence copayment waived upon
inpatient admission.
Emergency medical
transportation
50% coinsurance
50% coinsurance
None
Urgent care
$80/visit; deductible does not apply
Not Covered
Must be affiliated with member's chosen
medical group or referral required.
If you have a hospital
stay
Facility fee (e.g., hospital
room)
$500/visit plus 50% coinsurance
Not Covered
Referral required.
Physician/surgeon fees
No Charge; deductible does not apply
Not Covered
Referral required.
Page 4 of 6
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross
and Blue Shield Association
SBC-IL-HMO-IND-2023
*For more information about limitations and exceptions, see the plan or policy document at www.bcbsil.com/bb/ind/bb-shsa33baviilp-il-2023.pdf.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Important Information
Participating Provider
(You will pay the least)
Non-Participating Provider
(You will pay the most)
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services
$70/office visit; deductible does not
apply
50% coinsurance for other outpatient
services
Not Covered
Referral may be required. Telepsychiatry
benefits are available; see your benefit
booklet* for details.
Inpatient services
$500/visit plus 50% coinsurance
Not Covered
Referral required.
If you are pregnant
Office visits
Primary Care: $70
Specialist: $95; deductible does not
apply
Not Covered
Copayment applies to first prenatal visit
(per pregnancy). Cost sharing does not
apply for preventive services. Depending
on the type of services, deductible or
coinsurance may apply. Maternity care may
include tests and services described
elsewhere in the SBC (i.e., ultrasound).
Childbirth/delivery
professional services
No Charge; deductible does not apply
Not Covered
Childbirth/delivery facility
services
$500/visit plus 50% coinsurance
Not Covered
If you need help
recovering or have
other special health
needs
Home health care
No Charge; deductible does not apply
Not Covered
Referral required.
Rehabilitation services
$90/visit; deductible does not apply
Not Covered
Referral required.
Habilitation services
$90/visit; deductible does not apply
Not Covered
Skilled nursing care
50% coinsurance
Not Covered
Referral required.
Durable medical equipment
No Charge; deductible does not apply
Not Covered
Referral required.
Hospice services
50% coinsurance
Not Covered
Referral required.
If your child needs
dental or eye care
Children’s eye exam
No Charge; deductible does not apply
Not Covered
One visit per year. See your benefit
booklet* for details.
Children’s glasses
No Charge; deductible does not apply
Not Covered
One pair of glasses per year up to age 19.
See your benefit booklet* for details.
Children’s dental check-up
Not Covered
Not Covered
None
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Acupuncture
• Dental care (Adult)
• Long-term care
• Non-emergency care when traveling
outside the U.S.
• Weight loss programs
Page 5 of 6
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross
and Blue Shield Association
SBC-IL-HMO-IND-2023
*For more information about limitations and exceptions, see the plan or policy document at www.bcbsil.com/bb/ind/bb-shsa33baviilp-il-2023.pdf.
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Abortion care
• Bariatric surgery
• Chiropractic care (Chiropractic and
Osteopathic manipulation limited to 25
visits per calendar year)
• Cosmetic surgery (only for the correction of
congenital deformities or conditions
resulting from accidental injuries, scars,
tumors, or diseases)
• Hearing aids (for children 1 per ear every
24 months, for adults up to $2,500 per ear
every 24 months)
• Infertility treatment (covered for 4
procedures per benefit period)
• Private-duty nursing (with the exception of
inpatient private-duty nursing)
• Routine eye care (Adult, 1 visit per benefit
period)
• Routine foot care (when medically
necessary)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the
plan at 1-800-892-2803. You may also contact your state insurance department at 1-877-527-9431. Other coverage options may be available to you, too, including buying
individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide
complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
Blue Cross and Blue Shield of Illinois at 1-800-892-2803 or visit www.bcbsil.com, or contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-
866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of
Insurance at 1-877-527-9431 or visit http://insurance.illinois.gov.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,
TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Not Applicable
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-892-2803.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-892-2803.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-892-2803.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-892-2803.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 6 of 6
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross
and Blue Shield Association
SBC-IL-HMO-IND-2023
The plan would be responsible for the other costs of these EXAMPLE covered services.
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)
Mia’s Simple Fracture
(in-network emergency room visit and follow
up care)
Managing Joe’s Type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)
◼ The plan’s overall deductible $7,500
◼ Specialist copayment $95
◼ Hospital (facility) copay/coins $500+50%
◼ Other coinsurance 50%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
$6,600
Copayments
$1,500
Coinsurance
$0
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$8,160
◼ The plan’s overall deductible $7,500
◼ Specialist copayment $95
◼ Hospital (facility) copay/coins $500+50%
◼ Other coinsurance 50%
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles
$0
Copayments
$2,100
Coinsurance
$0
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is
$2,120
◼ The plan’s overall deductible $7,500
◼ Specialist copayment $95
◼ Hospital (facility) copay/coins $500+50%
◼ Other coinsurance 50%
This EXAMPLE event includes services like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles
$1,600
Copayments
$1,100
Coinsurance
$0
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$2,700
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language assistance. We
do not discriminate on the basis of race, color, national origin, sex, gender identity, age, sexual orientation, health
status or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)
300 E. Randolph St. TTY/TDD: 855-661-6965
35
th
Floor Fax: 855-661-6960
Chicago, Illinois 60601
You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:
U.S. Dept. of Health & Human Services Phone: 800-368-1019
200 Independence Avenue SW TTY/TDD: 800-537-7697
Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
