BlueChoice®
The Blue Cross and Blue Shield of Illinois (BCBSIL) BlueChoice plan combines the flexibility of a PPO with the wide range of benefits of an HMO. Benefits include medical coverage, emergency care, vision services and more.
The BlueChoice plan gives you the choice of doctors and hospitals from a broad network—coverage that extends from preventive care to chronic care, and the flexibility to direct your own care.
With BlueChoice, each time you seek medical care, you have the freedom to coordinate your health care through a BlueChoice contracting doctor or hospital, or self-direct to a non-network doctor or hospital.
- You select a primary care physician (PCP) from the contracting physician network.
- When care is provided or coordinated by your PCP, your benefits are paid at the higher, in-network level.
- You receive referrals from your primary care physician to network specialists and medical facilities.
- If you prefer to direct your own care and go outside the network, your benefits are paid at the lower, out-of-network level.
BlueChoice Advantages
With the BlueChoice plan, benefits include coverage for:
- Doctor office visits
- Inpatient hospital services
- Outpatient hospital services
- Outpatient surgery and diagnostic tests
- Maternity services
- Hospital emergency medical and accident treatment
- Prescription drug benefits (including home delivery services)
- Breast cancer screenings
- Physical, occupational and speech therapy services
- Mental health and substance abuse treatment
- Reconstructive surgery following a mastectomy
Preventive Care
BlueChoice includes coverage for preventive care services for well-child and adult care, such as:
- Physical exams and checkups
- Immunizations
- Diagnostic tests
- Prenatal and routine gynecological care
Group plan coverage may vary.
The BlueChoice plan provides emergency care coverage for members, even when traveling out-of-state or abroad.
- In an emergency, members can seek care from any emergency room or other similar facility.
- Members can call 911 or other community emergency resources to obtain assistance in life-threatening situations.
- Emergency room care at any hospital is covered. All emergencies are paid at the in-network benefit level less the copayment, no matter where the member receives treatment.
- If a member is admitted to the hospital from the emergency room, they need to notify the Medical Support Program within 48 hours to receive the highest level of benefits.
- If possible, a member should call their primary care physician first, as the doctor may be able to treat them in the office.
Whether you’re traveling across the country or around the world, you can take your BCBSIL BlueChoice health care benefits with you.
National Coverage
The BlueChoice plan provides coverage when members are away from home.
- Should an emergency situation arise, you should seek medical treatment immediately.
- Eligible services are covered when emergency care is needed.
- If you are admitted to a hospital, you or someone on your behalf must call the Medical Support Program to pre-notify your admission within 48 hours so that you may receive the highest level of benefits.
- In a non-emergency situation, try calling your doctor first. He or she may be able to assist you over the phone.
- Doctor visits for non-emergency care are paid at the out-of-network benefit level.
International Coverage
When you travel outside the United States and need urgent or immediate care, you are covered. Seek medical assistance where you can. Medical coverage varies, based on your employer's benefit plan. Save all medical receipts for submitting a claim, then call your doctor when you return home to coordinate care.
Federal and State of Illinois laws require group health plans and insurers to provide coverage for reconstructive surgery following a mastectomy. These laws state that health plans that cover mastectomies must also provide coverage in a manner determined in consultation with the attending physician and patient for:
- Reconstruction of the breast on which the mastectomy has been performed;
- Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
- Prostheses and treatment for physical complications for all stages of mastectomy, including lymphedemas.
BCBSIL plans traditionally offered this coverage before it was required. We continue to provide this coverage if the procedures are provided by a licensed physician according to each plan’s provisions. Coverage may also include benefits for annual mammograms.
If you have prescription drug coverage through BCBSIL:
- Your coverage may be based on either the standard formulary
or the generics plus formulary - Your benefit plan includes a mail service program that offers you the convenience of having covered maintenance medications delivered directly to you.
- Your plan also includes a specialty pharmacy program, through which members using covered self-injectable medications can have them delivered directly to them or their doctor, as well as receive services that may help them in managing their therapy.
View the Specialty Pharmacy Program Drug List which includes a reminder about coverage for self-administered specialty medications. - Helpful information is provided to assist you in understanding your prescription drug coverage and options, including convenient services and any limitations.
- A variety of online tools are available that can help you learn more about prescription drugs and manage your pharmacy benefits. Just log in to Blue Access for MembersSM and visit your Rx Drugs page.
