BlueAdvantage^SM HMO and HMO Value Choice
(2-50 Employees)

HMO options offer flexible plan designs and a wide range of benefits. Each covered family member can choose his or her own primary care physician (PCP) and a medical group/Independent Practice Association (IPA). Female members may also select a Woman's Principal Health Care Provider (WPHCP) to coordinate obstetric and gynecological care. The WPHCP and PCP must be affiliated with or employed by the member's Participating Medical Group. Physicians in the same medical group have a referral arrangement. Other advantages include predictable copayments, no claim forms or other paperwork, and no deductibles to meet.

BlueAdvantage HMO offers a broad network of PCPs and hospitals. HMO Value Choice offers an innovative three-tier copayment structure and reduced premiums.

The chart below presents the different BlueAdvantage HMO and HMO Value Choice options. It is organized by PCP office visit copays and includes out-of-pocket maximums and inpatient hospital, emergency room, specialist and office visit/wellness copayment amounts.

HMO reminders, contact information and the three tier prescription drug options can be found below the chart.

BlueAdvantage HMO Plan Options

Office Visit / Wellness Copay	Specialist Copay	Emergency Room Copay	Inpatient Hospital Copay	Out-of-Pocket Maximum (Individual/Family)
$20 PCP Office Visit Copay
$20 / $0	$40	$150	n/a	$1,500 / $3,000
$20 / $0	$40	$150	$100 per day for the 1^st five days per calendar year	$1,500 / $3,000
$30 PCP Office Visit Copay
$30 / $0	$50	$150	n/a	$1,500 / $3,000
$30 / $0	$50	$150	$250 per day for the 1^st five days per calendar year	$1,500 / $3,000

HMO Value Choice Plan Options

Wellness Copay	Specialist Copay	Emergency Room Copay	Inpatient Hospital Copay	Out-of-Pocket Maximum (Individual/Family)
$40 PCP Office Visit Copay
$0	$60	$250	$500 for 1^st three days	$3,000 / $6,000
$50 PCP Office Visit Copay
$0	$70	$300	$750 for 1^st three days	$3,000 / $6,000

Contact Us

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

HMO Reminder

All HMO services must be coordinated through the member's PCP/WPHCP.

Inpatient and outpatient mental health care is coordinated by a referral from the member's PCP. Inpatient and outpatient chemical dependency treatment is provided at contracting facilities and accessed directly, without a PCP referral, through the behavioral health network. (Note: Members of the Physicians Care Network, Inc. (PCN) do not need a referral for mental health care; the care is coordinated directly with the behavioral health network provider.)

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.

$15 / $30 / $50
$15 / 35% / 50%
$10 / $40 / $60