HMO Scope of Benefits

HMO Illinois®, Blue Advantage HMOSM, Blue Precision HMOSM, BlueCare DirectSM and Blue FocusCareSM

This page is intended to provide a quick reference of covered and non-covered services. It includes frequently asked benefit issues and issues that have been misinterpreted in the past. However, it is not possible to include everything. Additional information regarding benefits and/or financial responsibility can be found in the Medical Service Agreement. The IPA may contact the Customer Assistance Unit Staff at 312-653-6600 for more help with benefits interpretation. Read Introduction

Guideline for Benefit Interpretation

Reviewed

Abortion

5/1/2022

Acupuncture

5/1/2022

Allergy Testing/Desensitization

5/1/2022

Ambulance Services

5/1/2022

Ambulatory Blood Pressure Monitoring

5/1/2022

Amniocentesis

5/1/2022

Apnea Monitors

5/1/2022

Assistant Surgeon

5/1/2022

Autism Spectrum Disorder (ASD)

5/1/2022

Automatic External Defibrillator

5/1/2022

Automatic Implantable Cardioverter Defibrillator (AICD)

5/1/2022

Autopsy Examination

5/1/2022

BRCA (Breast Cancer Susceptibility) Testing and Related Genetic Counseling

5/1/2022

Biofeedback Therapy

5/1/2022

Blood and Blood Derivatives

5/1/2022

Boarder Babies

5/1/2022

Bone Marrow Transplantation

5/1/2022

Botulinum Toxin

5/1/2022

Breast Screening

5/1/2022

Breast Surgery

5/1/2022

Cardiac Rehabilitation

5/1/2022

CAR-T Therapy

5/1/2022

Chemical Dependency/Substance Use Disorder (SUD) Services

5/1/2022

Chemotherapy

5/1/2022

Chiropractic Services

5/1/2022

Cochlear Implantation

5/1/2022

Cognitive Therapy

5/1/2022

Collagen Implant

5/1/2022

Computerized Knee Evaluation

5/1/2022

Contact Lenses/Eyeglasses

5/1/2022

Cosmetic/Reconstructive Surgery

5/1/2022

Custodial Care

5/1/2022

Day Rehabilitation Program

5/1/2022

Dental

5/1/2022

Diabetes Self-Management

5/1/2022

Drugs

5/1/2022

Durable Medical Equipment (DME)

5/1/2022

Earplugs

5/1/2022

Electrical Bone Growth Stimulation

5/1/2022

Emergency Communication Devices

5/1/2022

Emergency Services

5/1/2022

Epidural Anesthesia

5/1/2022

Erythropoietin (EPO)

5/1/2022

Family Planning

5/1/2022

Growth Factors for Wound Healing

5/1/2022

Growth Hormone Therapy

5/1/2022

Health Examinations

5/1/2022

Hearing Aids

5/1/2022

Hearing Screening

5/1/2022

Hematopoietic Growth Factors (HGF)

5/1/2022

Hemodialysis and Peritoneal Dialysis

5/1/2022

Hepatitis B Vaccine

5/1/2022

Home Health Care Services

5/1/2022

Home Uterine Activity Monitoring (HUAM)

5/1/2022

Hospice Care

5/1/2022

Hospital Beds

5/1/2022

Hyperalimentation (TPN)

5/1/2022

Hyaluronan (Durolane, Orthovisc, Monovisc, Euflexxa, Supartz, Hymovis, Gel-ONE, GelSyn-3, GenVisc 850, Hyalgan, Visco-3, Synvisc/Synvisc-One and TriVisc)+

5/1/2022

Hyperthermia Therapy

5/1/2022

Hypnotherapy (Hypnosis)

5/1/2022

Immunizations

5/1/2022

Infertility and Fertility Treatment

8/2022

Infusion Pumps (Implanted-Permanent)

5/1/2022

Infusion Pumps (Portable - Temporary)

5/1/2022

Intravenous Immunoglobulin (IVIG)

5/1/2022

Investigational Procedures, Drugs, Devices, Services, and/or Supplies

5/1/2022

Laboratory Tests

5/1/2022

Lithotripsy (Percutaneous and Extracorporeal)

5/1/2022

Lupron/Lupron Depot

5/1/2022

Mammography

5/1/2022

Maternity/Obstetrical Care

5/1/2022

Medical Supplies (Non-Durable Medical Equipment)

5/1/2022

Mental Health Care (Inpatient)

5/1/2022

Mental Health Care (Outpatient)

5/1/2022

Monoclonal Antibody Imaging

5/1/2022

Naprapathic Services

5/1/2022

Nerve Stimulators (Percutaneous, Transcutaneous, Implanted)

5/1/2022

Neuromuscular Stimulation for Scoliosis

5/1/2022

Nutritional Services (Dietary Counseling)

5/1/2022

Nutritional Supplements/Enteral Nutrition

5/1/2022

Obesity

5/1/2022

Obstructive Sleep Apnea (OSA) Syndrome

5/1/2022

Occupational Therapy

5/1/2022

Oral Surgery

5/1/2022

Organ and Tissue Transplantation

8/2022

Orthodontics

5/1/2022

Orthognathic Surgery

5/1/2022

Orthotic Devices

5/1/2022

Outpatient Surgery

5/1/2022

Oxygen

5/1/2022

Pain Management Programs

5/1/2022

Physical Therapy

5/1/2022

Podiatry/Podiatric Services

5/1/2022

Pre-implantation Genetic Diagnosis (PGD) – Infertility Related

5/1/2022

Pre-implantation Genetic Diagnosis (PGD) – Non-infertility Related

5/1/2022

Private Duty Nursing

5/1/2022

Prostate Procedures

5/1/2022

Prosthetic Devices

5/1/2022

Pulmonary Rehabilitation

5/1/2022

Refractive Keratoplasty

5/1/2022

Respiratory Therapy (Inhalation Therapy)

5/1/2022

Seat Lift

5/1/2022

Second Opinions

5/1/2022

Sensory Evoked Potentials (SEP)

5/1/2022

Skilled Nursing Facility (SNF)

5/1/2022

Speech Therapy

5/1/2022

Sterilizations

5/1/2022

Synagis®

5/1/2022

Temporomandibular Joint Disorder

5/1/2022

Tobacco Cessation

5/1/2022

Transgender Services

5/1/2022

Ultraviolet Light Treatment for Psoriasis

5/1/2022

Vision Screening/Routine Vision Care

5/1/2022

Well Child Care

5/1/2022

Wheelchairs

5/1/2022