A Division of Health Care Service Corporation a Mutual Legal Reserve C - PDF document

1 A Division of Health Care Service Corpor
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association B E NEFI T H GHLI GHT S This provides only highlights of the benefit plan. After enrollment, members will receive a Certificate that more fully describes the terms of coverage.Lifetime Benefit MaximumIndividual Coverage DeductibleFamily Coverage DeductibleIndividual Coverage Out-of-Pocket Expense (OPX) LimitFamily Coverage Out-of-Pocket Expense (OPX) LimitPhysician Office VisitsSpecialist Office Visitsreventive CareMaternity Services Services Inpatient Hospital ServicesOutpatient Hospital ServicesOutpatient Emergency Care (Accident or Illness) Emergency Medical and Emergency ccident. pplies to both in-andout-of-networemergencyroomvisits.The per-occurrence is waived if the member is admitted to the hospital. $100 per Coverage for services includes, but is not limited to outpatient or ambulatorysurgical procedures,x-ray,labtests, chemotherapy, radiation therapy, renal dialysis, and mammograms performed in a hospital or ambulatorysurgical center, including mental health and substance abuse services. Routine mammograms performed in an in-network outpatient hospital settin are paable at 100%, no deductiblewillapply. after deductible afterdeductible seingcoordinatednd aftedeductible aftedeductible Hosp ita l S e rv ic es aftedeductible aftedeductible ies tofirst prenatalvisiter pregnancy)thermaternityphysiciancoveredservicesarepaid theameMedical /SurgicalServices. $ Copay aftedeductible Services that have a rating of “A” or “B” in the current recommendationsoftheUnitedStatesPreventiveServices Task Force (“USPSTF”). Includes benefits for routine physical examinations, well child care and aftedeductible One copayment per day when you receive services from a specialist.Surgeries,therapiesandcertaindiagnostic procedures performed in a physician’s office may be subjecttothedeductibleand/orcoinsurance. $0 Copay afterdeductible One copayment per day when you receive services from a FamilyPractice,InternalMedicine,OB/GYN,orPediatrician. Surgeries, therapies and certain diagnostic procedures performed in a physician’s office may besubject to the deductible and/or coinsurance, including mental healthandsubstanceabuseservices. $ Copay afterdeductible Phys ici a n Ser v i ces $,00 $,00 The amount of money that any individual will have to pay toward coveredcalendar year, ncluding the deductiblThe follo

2 wing items will be applied to the out-of
wing items will be applied to the out-of-pocket $,000 $,000 Per calendar ear. $,000 $,000 Per calendar ear. $,000 $,000 Per individualUnlimited Non-PPO(Out-of-Network) PPO (In-Network) Prog ram Ba sic s hampaign County Deductible, $ PPO Net w or k on Exams Vision screenings and examinations for determining the refractive state of the eyes are covered. Po materials are covered under this benefit. $0 Copay A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 2of B E NEFI T HI GHLI GHT S Muscle Manipulation ServicesTherapy Services – Speech, Occupational and PhysicalTemporomandibular Joint (TMJ) Dysfunction and Related DisordersOther Covered ServicesPrescription Drug Card www.bcbsil.com/providers Please refer to yofits or you policyling CustomeService, for additionaletailsscription ofcare refulliew the plan’slimitatioxclusions.Out of network benefits are subject to maximum allowable charge limitations which will limit the amount of charges that will be allowed or considered to be eligible to be paid. This means that generally less than the full amount of the charge will count toward the out of network deductible and less than the full amount of the charge will be covered at the out of network coinsurance limit. Members will be responsible for the differences between the allowed amount and the amount (if any) that the insurance plan will pay. CVS (including CVS inside a Target Store) and Doc's Drugs are not covered pharmacies under this BCBS Plan.Benefits at pharmacy are at 75% the amount that would have appropriate copayment M ailOrder: 2 X retail copay,90-day suppl y maintenance drugs (specialty drugs not available thru mailorder ) Private duty nursing (Please refer to Certificate for details)Artificial limbs and other prosthetic devicesBlood and blood componentsSkilled Nursing A mbulanceservicesOrthotic appliances Prosthetic appliancesMedicalsupplies aftedeductible aftedeductible aftedeductible aftedeductible Covera g e for services p rovided b y a p h y sician or thera p ist. aftedeductible aftedeductible Coverage for spinal and muscle manipulation services provided bya physicianorchiropractor.Relatedofficevisits are paid the same as other Physician Office Visits. aftedeductible aftedeductible Maximum of 30 visits pe r calenda r y ea r Addi tio n al Se rvi ces PPO Net w or k hampaign County Deductible, PPO (In-Network) Non-PPO(Out-of-Network)