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Blue Access for Employers

Participating Provider Option (PPO)
(51-150) Employees

PPO offers a wide range of benefit designs that offer options for coinsurance, deductible and out-of-pocket maximums, as well as office visit and three-tier drug card copayments. PPO members are not required to select a primary care physician and have the freedom to choose a doctor whenever they need care, including specialists, from one of the largest PPO networks in Illinois. When members use contracting network doctors and hospitals, there are no claim forms to complete and no "balance billing" because providers agree to accept Blue Cross and Blue Shield of Illinois' negotiated rates.

This chart below presents the different options available within this product and a comparison of in-network benefits versus out-of-network Benefits. Contact information, a mental health care coordination reminder and the three tier formulary prescription drug options can be found below the chart.



In-Network Benefits — 100% / 80% Coinsurance

Coinsurance Deductible(Individual/Family) Out-of-Pocket Max*(Individual/Family) Office Visit/
PCP/PSP		 Emergency Room Copay
$500 DEDUCTIBLE
100% $500 / $1,500 $0 / $0 $20 / $40 $150

Out-of-Network Benefits

Coinsurance Deductible(Individual/Family) Out-of-Pocket Max*(Individual/Family)
$500 DEDUCTIBLE
80% $1,000 / $3,000 $1,000 / $3,000

In-Network Benefits — 90% / 70% Coinsurance

Coinsurance Deductible(Individual/Family) Out-of-Pocket Max*(Individual/Family) Office Visit/
PCP/PSP		 Emergency Room Copay
$500 DEDUCTIBLE
90% $500 / $1,500 $500 / $1,500 $20 / $40 $150
90% $500 / $1,500 $1,000 / $3,000 $20 / $40 $150
90% $500 / $1,500 $2,000 / $6,000 $20 / $40 $150
$1,000 DEDUCTIBLE
90% $1,000 / $3,000 $500 / $1,500 $20 / $40 $150
90% $1,000 / $3,000 $1,000 / $3,000 $20 / $40 $150
90% $1,000 / $3,000 $2,000 / $6,000 $20 / $40 $150
$1,500 DEDUCTIBLE
90% $1,500 / $4,500 $1,000 / $3,000 $20 / $40 $150
90% $1,500 / $4,500 $2,000 / $6,000 $20 / $40 $150
90% $2,500 / $7,500 $1,000 / $3,000 $20 / $40 $150
90% $2,500 / $7,500 $2,000 / $6,000 $20 / $40 $150
$3,500 DEDUCTIBLE
90% $3,500 / $10,500 $1,000 / $3,000 $20 / $40 $150
90% $3,500 / $10,500 $2,000 / $6,000 $20 / $40 $150

Out-of-Network Benefits

Coinsurance Deductible(Individual/Family) Out-of-Pocket Max*(Individual/Family)
$500 DEDUCTIBLE
70% $1,000 / $3,000 $1,500 / $4,500
70% $1,000 / $3,000 $2,000 / $6,000
70% $1,000 / $3,000 $4,000 / $12,000
$1,000 DEDUCTIBLE
70% $2,000 / $6,000 $1,500 / $4,500
70% $2,000 / $6,000 $2,000 / $6,000
70% $2,000 / $6,000 $4,000 / $12,000
$1,500 DEDUCTIBLE
70% $3,000 / $9,000 $2,000 / $6,000
70% $3,000 / $9,000 $4,000 / $12,000
70% $5,000 / $15,000 $2,000 / $6,000
70% $5,000 / $15,000 $4,000 / $12,000
$3,500 DEDUCTIBLE
70% $7,000 / $21,000 $2,000 / $6,000
70% $7,000 / $21,000 $4,000 / $12,000

In-Network Benefits — 80% / 60% Coinsurance

Coinsurance Deductible(Individual/Family) Out-of-Pocket Max*(Individual/Family) Office Visit/
PCP/PSP		 Emergency Room Copay
$500 DEDUCTIBLE
80% $500 / $1,500 $1,000 / $3,000 $20 / $40 $150
80% $500 / $1,500 $1,000 / $3,000 $30 / $50 $150
80% $500 / $1,500 $2,000 / $6,000 $20 / $40 $150
80% $500 / $1,500 $2,000 / $6,000 $30 / $50 $150
80% $500 / $1,500 $3,000 / $9,000 $20 / $40 $150
80% $500 / $1,500 $3,000 / $9,000 $30 / $50 $150
$1,000 DEDUCTIBLE
80% $1,000 / $3,000 $1,000 / $3,000 $20 / $40 $150
80% $1,000 / $3,000 $1,000 / $3,000 $30 / $50 $150
80% $1,000 / $3,000 $2,000 / $6,000 $20 / $40 $150
80% $1,000 / $3,000 $2,000 / $6,000 $30 / $50 $150
80% $1,000 / $3,000 $3,000 / $9,000 $20 / $40 $150
80% $1,000 / $3,000 $3,000 / $9,000 $30 / $50 $150
$1,500 DEDUCTIBLE
80% $1,500 / $4,500 $1,000 / $3,000 $20 / $40 $150
80% $1,500 / $4,500 $1,000 / $3,000 $30 / $50 $150
80% $1,500 / $4,500 $2,000 / $6,000 $20 / $40 $150
80% $1,500 / $4,500 $2,000 / $6,000 $30 / $50 $150
80% $1,500 / $4,500 $3,000 / $9,000 $20 / $40 $150
80% $1,500 / $4,500 $3,000 / $9,000 $30 / $50 $150
$2,500 DEDUCTIBLE
80% $2,500 / $7,500 $1,000 / $3,000 $20 / $40 $150
80% $2,500 / $7,500 $1,000 / $3,000 $30 / $50 $150
80% $2,500 / $7,500 $2,000 / $6,000 $20 / $40 $150
80% $2,500 / $7,500 $2,000 / $6,000 $30 / $50 $150
80% $2,500 / $7,500 $3,000 / $9,000 $20 / $40 $150
80% $2,500 / $7,500 $3,000 / $9,000 $30 / $50 $150
$3,500 DEDUCTIBLE
80% $3,500 / $10,500 $1,000 / $3,000 $20 / $40 $150
80% $3,500 / $10,500 $1,000 / $3,000 $30 / $50 $150
80% $3,500 / $10,500 $2,000 / $6,000 $20 / $40 $150
80% $3,500 / $10,500 $2,000 / $6,000 $30 / $50 $150
80% $3,500 / $10,500 $3,000 / $9,000 $20 / $40 $150
80% $3,500 / $10,500 $3,000 / $9,000 $30 / $50 $150

Out-of-Network Benefits

Coinsurance Deductible(Individual/Family) Out-of-Pocket Max*(Individual/Family)
$500 DEDUCTIBLE
60% $1,000 / $3,000 $2,000 / $6,000
60% $1,000 / $3,000 $2,000 / $6,000
60% $1,000 / $3,000 $4,000 / $12,000
60% $1,000 / $3,000 $4,000 / $12,000
60% $1,000 / $3,000 $6,000 / $18,000
60% $1,000 / $3,000 $6,000 / $18,000
$1,000 DEDUCTIBLE
60% $2,000 / $6,000 $2,000 / $6,000
60% $2,000 / $6,000 $2,000 / $6,000
60% $2,000 / $6,000 $4,000 / $12,000
60% $2,000 / $6,000 $4,000 / $12,000
60% $2,000 / $6,000 $6,000 / $18,000
60% $2,000 / $6,000 $6,000 / $18,000
$1,500 DEDUCTIBLE
60% $3,000 / $9,000 $2,000 / $6,000
60% $3,000 / $9,000 $2,000 / $6,000
60% $3,000 / $9,000 $4,000 / $12,000
60% $3,000 / $9,000 $4,000 / $12,000
60% $3,000 / $9,000 $6,000 / $18,000
60% $3,000 / $9,000 $6,000 / $18,000
$2,500 DEDUCTIBLE
60% $5,000 / $15,000 $2,000 / $6,000
60% $5,000 / $15,000 $2,000 / $6,000
60% $5,000 / $15,000 $4,000 / $12,000
60% $5,000 / $15,000 $4,000 / $12,000
60% $5,000 / $15,000 $6,000 / $18,000
60% $5,000 / $15,000 $6,000 / $18,000
$3,500 DEDUCTIBLE
60% $7,000 / $21,000 $2,000 / $6,000
60% $7,000 / $21,000 $2,000 / $6,000
60% $7,000 / $21,000 $4,000 / $12,000
60% $7,000 / $21,000 $4,000 / $12,000
60% $7,000 / $21,000 $6,000 / $18,000
60% $7,000 / $21,000 $6,000 / $18,000

* The out-of-pocket maximum does not include the deductible.



Contact Us

Blue Cross and Blue Shield of Illinois
300 East Randolph Street
Chicago, Illinois 60601-5099
(800) 654-7385

Three-Tier Formulary Prescription Drug Card

Each health product can be paired with one of three prescription drug cards. Drug card copayments are listed in the following order: Generic / Preferred / Non Preferred.

  1. $15 / $30 / $50
  2. $15 / 35% / 50%
  3. $10 / $40 / $60

 
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