Community Participating Option and Community Participating Option Value Choice
(2-150) Employees

Community Participating Option (CPO) offers members in certain geographic areas the convenience of affordable care from local health care providers with a three-tier network. Members can see doctors in that network and receive the highest level of benefits. CPO members also have access to PPO providers, but benefits are paid at a lower level.

CPO Value Choice offers the same coverage as the standard CPO, but includes higher deductible amount.

The chart below presents the different CPO plan options and includes a comparison of in-network versus out-of-network benefits. Contact information, a mental health care coordination reminder prescription drug information can be found below the charts.

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CPO Plan Options (Standard)

CPO In-Network Benefits — 90% / 80% / 60% Coinsurance

Coinsurance	Deductible (Individual/Family)	Out-of-Pocket Max* (Individual/Family)	Office Visit/ Copay
90%	$500 /$1,500	$2,000 /$6,000	$20

PPO In-Network Benefits

Coinsurance	Deductible (Individual/Family)	Out-of-Pocket Max* (Individual/Family)	Office Visit/ Copay
80%	$1,000/$3,000	$4,000/$12,000	$20

Out-of-Network Benefits

Coinsurance	Deductible (Individual/Family)	Out-of-Pocket Max* (Individual/Family)	Office Visit/ Copay
60%	$2,000/$6,000	$12,000/$36,000	60% (after deductible has been met)

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

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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CPO Value Choice Plan Options — 90% / 80% / 50%

CPO Value Choice In-Network Benefits

Coinsurance	Deductible (Individual/Family)	Out-of-Pocket Max* (Individual/Family)	Office Visit/ Copay
90%	$1,000/$3,000	$1,000/$3,000	$20
90%	$2,500/$7,500	$2,500/$7,500	$20
90%	$5,000/$15,000	$5,000/$15,000	$20

PPO In-Network Benefits

Coinsurance	Deductible (Individual/Family)	Out-of-Pocket Max* (Individual/Family)	Office Visit/ Copay
80%	$2,000/$6,000	$2,000/$6,000	$20
80%	$5,000/$15,000	$5,000/$15,000	$20
80%	$10,000/$30,000	$10,000/$30,000	$20

Out-of-Network Benefits

Coinsurance	Deductible (Individual/Family)	Out-of-Pocket Max* (Individual/Family)	Office Visit/ Copay
50%	$4,000/$12,000	$4,000/$12,000	50% (after deductible has been met)
50%	$10,000/$30,000	$10,000/$30,000	50% (after deductible has been met)
50%	$15,000/$45,000	$15,000/$45,000	50% (after deductible has been met)

Prescription drugs are covered at the medical coinsurance benefit noted in the chart above.

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Contact Us

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