MyBlue Plus Silver 905
Blue Cross and Blue Shield of Illinois
Plan overview
Medical deductible
Individual: $5000
Family: $10000
Per Person: $5000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8000
Family: $16000
Per Person: $8000
Office visit
Primary Doctor
CoPay:
CoInsurance:
Covered:
Benefit Explanation:
Specialist
CoPay:
CoInsurance:
Covered:
Prescription drug information
Preferred brand drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Inpatient coverage
Hospital services
CoPay:
CoInsurance:
Covered:
Inpatient services
CoPay:
CoInsurance:
Covered:
Emergency and urgent care
Emergency room
CoPay:
CoInsurance:
Covered:
Urgent care facility
CoPay:
CoInsurance:
Covered:
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay:
CoInsurance:
Covered:
Pre and Postnatal office visit
CoPay:
CoInsurance:
Covered:
Vision
Routine Eye Exams for Children
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).
- HealthMarkets Insurance Agency d/b/a Insphere Insurance Solutions, Inc is an independent, authorized agent for Blue Cross and Blue Shield of Illinois.
- 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.
- Effective dates are available on the first of the month only, unless otherwise required by law. Applications must be received by Blue Cross and Blue Shield of Illinois within the defined enrollment period to be accepted.