Blue PPO SilverSM 104.pdf

Blue Cross and Blue Shield of Illinois' Blue PPO Silver 104 plan has the following benefits:
- Lifetime Maximum: Unlimited
- Individual Deductible: $5,000 (Participating Provider), $10,000 (Non-Participating/Non-Plan Provider)
- Family Deductible: $15,000 (Participating Provider), $30,000 (Non-Participating/Non-Plan Provider)
- Individual Out-of-Pocket Expense Limit: $9,100 (Participating Provider), Unlimited (Non-Participating/Non-Plan Provider)
- Family Out-of-Pocket Expense Limit: $18,200 (Participating Provider), Unlimited (Non-Participating/Non-Plan Provider)
- Inpatient Hospital Benefits: $250 copayment per admission, 70% of Eligible Charge (Participating Provider), $350 copayment per admission, 50% of Eligible Charge (Non-Participating Provider)
- Outpatient Hospital Benefits: $200 copayment per visit, 70% of Eligible Charge (Participating Provider), $300 copayment per visit, 50% of Eligible Charge (Non-Participating Provider)
- Urgent Care: $75 copayment, no deductible (Participating Provider)
- Outpatient Laboratory Services: 70% of Eligible Charge (Participating Provider), 50% of Eligible Charge (Non-Participating Provider)
- Outpatient Surgical/Medical Services: $200 copayment per visit, 70% of Eligible Charge (Participating Provider), $300 copayment per visit, 50% of Eligible Charge (Non-Participating Provider)
- Physician Benefits: 70% of Maximum Allowance (Participating Provider), 50% of Maximum Allowance (Non-Participating Provider)
- Emergency Accident Care: 70% of Maximum Allowance
- Emergency Medical Care: 70% of Maximum Allowance
- Office Visits: $45 copayment, 100% of Maximum Allowance (Participating Provider, non-specialist), $65 copayment, 100% of Maximum Allowance (Participating Provider, specialist)