b'UnitedHealthcare Choice Plus PPO Blue Cross Blue ShieldHMO Illinois (HMOI)PROFESSIONAL AND OTHER SERVICES PROFESSIONAL AND OTHER SERVICESAllergy Shots Allergy ShotsNo charge$30 Office Visit CopayPhysician visit copay appliesAmbulance Ambulance80%PPO/Non-PPO after deductible No copayPrior authorization required for non-emergencyChiropractic VisitsChiropractic Visits $30 Copay80%PPO provider, after deductible Limited to 40 visits per year50%Non-PPO after deductibleLimited to 20 visits per year DentalAccidental care only: coverage provided for repair of Dental accidental injury to sound natural teeth80%PPO/Non-PPO after deductible Accident only; Prior authorization required Eyeglasses and ContactsMaternity Covered up to $75 allowance every 24 monthsSee applicable service for benefit level. Copay onlyContact EyeMed at 1-844-684-2254 for details applies to initial office visit for physician officeon the vision discount program. services.MaternityPhysician Office Visits 100% after $30 copay100% PPO provider, deductible does not apply $100Copay PPO specialist provider, deductible does Physician Office Visits not apply $30Copay50% Non-PPO provider after deductible Preventive Care Services (physicals, diagnostic Preventive Care Services (physicals, diagnostictests, immunizations)tests, some immunizations) No copay100% PPO for routine lab, x-rays, mammograms, Prosthetic Devices and Medical Equipmentpreventive tests. PPO preventive care not No copaysubject to deductible50% Non-PPO after deductible Vision Screening and ExamsProsthetic Devices and Medical Equipment $30Copay80% PPO after deductibleLimited to one screening/exam every 12 months50% Non-PPO after deductibleLimited to single purchase of each type of device every 3 yearsVision Screening and ExamsNot covered16 CTPF 2024 NON-MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2024 NON-MEDICARE HEALTH INSURANCE HANDBOOK'