b'Blue Cross Blue Shield PPO Blue Cross Blue ShieldHMO Illinois (HMOI)PROFESSIONAL AND OTHER SERVICES PROFESSIONAL AND OTHER SERVICESAllergy Shots Allergy Shots90% PPO provider $30 Office Visit Copay50% Non-PPO providerAmbulance Ambulance90% No copayChiropractic Visits Chiropractic Visits80% PPO provider $30 Copay50% Non-PPO provider Limited to 40 visits per yearLimited to 30 visits per yearDental DentalAccidental care only: coverage provided for repair of Accidental care only: coverage provided accidental injury to sound natural teethfor repair of accidental injury to sound natural teethEyeglasses and Contacts Eyeglasses and ContactsNot covered Covered up to $75 allowance every 24 monthsContact BCBS customer service at 1-800-331-8032 forContact EyeMed at 1-844-684-2254 for details details on the vision discount program. on the vision discount program. Physician Office Visits Physician Office Visits$10 Copay PPO provider Primary Care $30Copay$50 Copay PPO provider Specialist Preventive Care Services (physicals, diagnostic 50%Non-PPO provider tests, immunizations)Preventive Care Services No copay100% of allowed charges PPO and Prosthetic Devices and Medical Equipment50% non-PPO providers No copayIncludes routine physical examinations, routine tests, colorectal cancer screening, and immunizations Vision Screening and Exams$30CopayProsthetic Devices and Medical Equipment Limited to one screening/exam every 12 months90%PPO provider up to purchase price50% Non-PPO provider up to purchase priceVision Screening and ExamsNot coveredContact BCBS customer service at 1-800-331-8032 for details on the vision discount program.14 CTPF 2025 NON-MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2025 NON-MEDICARE HEALTH INSURANCE HANDBOOK'