Page 4 - CHI 2022 Benefits Guide
P. 4
Find an In- Medical Benefits
Network Option 1—PPO Option 2—HDHP
Provider In-Network Network In-Network Out-of-Network
Out-of-
Use Provider Finder to locate Annual Deductible
a network doctor, hospital, or Individual $1,500 $3,000 $2,800 $5,600
other healthcare provider on Family $3,000 $6,000 $5,600 $11,200
Blue Access for members at Out-of-Pocket Maximum (Medical and Prescription, includes Deductible)
www.bcbsil.com/member. Individual $4,500 $9,000 $6,650 $13,300
Family $9,000 $18,000 $13,300 $26,600
In-Network Hospital Services Ded. then 80% Ded. then 60% Ded. then 80% Ded. then 60%
Inpatient
Care Can Save Outpatient Ded. then 80% Ded. then 60% Ded. then 80% Ded. then 60%
You Money Emergency room Ded. then 80% Ded. then 80%
Oice Visits
Both medical plan options ofer Preventive care 100% covered Ded. then 60% 100% covered Ded. then 60%
you the choice of receiving care
from providers in or out of the Telemedicine
Blue Cross provider network. (general $20 copay Not covered Ded. then 80% Not covered
Using in-network providers can medicine)
save you money because these Telemedicine $40 copay Not covered Ded. then 80% Not covered
providers agree to charge you (dermatology)
pre-negotiated fees, and the Primary care $25 copay Ded. then 60% Ded. then 80% Ded. then 60%
plans cover in-network care at a Specialist $50 copay Ded. then 60% Ded. then 80% Ded. then 60%
higher rate. Neither plan requires Up to $25 per 60% up to $25 Ded. then up to Ded. then 60%
you to select a primary care Chiropractic care visit per visit $25 per visit up to $25 per
physician or obtain referrals to a visit
specialist. Urgent care $50 copay Ded. then 60% Ded. then 80% Ded. then 60%
Mental Health/Substance Abuse
Inpatient Ded. then 80% Ded. then 60% Ded. then 80% Ded. then 60%
Outpatient Ded. then 80% Ded. then 60% Ded. then 80% Ded. then 60%
Psychotherapy
oice visit $25 copay Ded. then 60% Ded. then 80% Ded. then 60%
Prescription Drugs (In-Network only)
Retail— 30-days
Supply Limit
Tier 1 $25 copay Deductible then 80%*
Tier 2 $50 copay Deductible then 80%*
Tier 3 $75 copay Deductible then 80%*
Tier 4—specialty 25%, $150 maximum copay Deductible then 80%*
Mail Order— 90-days
Supply Limit
Tier 1 $50 copay Deductible then 80%*
Tier 2 $100 copay Deductible then 80%*
Tier 3 $150 copay Deductible then 80%*
Tier 4—specialty 25%, $150 maximum copay Deductible then 80%*
* The Preventive Drug Program covers certain preventive drugs at 100% with the deductible
waived. For a list of preventive medication contact C.H.I. Human Resources.
Diagnostic work, lab tests, and x-rays performed in the oice visit setting are subject to the
deductible and coinsurance.
There is a penalty for failure to pre-certify services out-of-network.
This summary is a highlight of the beneit provisions and should not be relied upon as a complete
detailed representation of the plan.
4
Network Option 1—PPO Option 2—HDHP
Provider In-Network Network In-Network Out-of-Network
Out-of-
Use Provider Finder to locate Annual Deductible
a network doctor, hospital, or Individual $1,500 $3,000 $2,800 $5,600
other healthcare provider on Family $3,000 $6,000 $5,600 $11,200
Blue Access for members at Out-of-Pocket Maximum (Medical and Prescription, includes Deductible)
www.bcbsil.com/member. Individual $4,500 $9,000 $6,650 $13,300
Family $9,000 $18,000 $13,300 $26,600
In-Network Hospital Services Ded. then 80% Ded. then 60% Ded. then 80% Ded. then 60%
Inpatient
Care Can Save Outpatient Ded. then 80% Ded. then 60% Ded. then 80% Ded. then 60%
You Money Emergency room Ded. then 80% Ded. then 80%
Oice Visits
Both medical plan options ofer Preventive care 100% covered Ded. then 60% 100% covered Ded. then 60%
you the choice of receiving care
from providers in or out of the Telemedicine
Blue Cross provider network. (general $20 copay Not covered Ded. then 80% Not covered
Using in-network providers can medicine)
save you money because these Telemedicine $40 copay Not covered Ded. then 80% Not covered
providers agree to charge you (dermatology)
pre-negotiated fees, and the Primary care $25 copay Ded. then 60% Ded. then 80% Ded. then 60%
plans cover in-network care at a Specialist $50 copay Ded. then 60% Ded. then 80% Ded. then 60%
higher rate. Neither plan requires Up to $25 per 60% up to $25 Ded. then up to Ded. then 60%
you to select a primary care Chiropractic care visit per visit $25 per visit up to $25 per
physician or obtain referrals to a visit
specialist. Urgent care $50 copay Ded. then 60% Ded. then 80% Ded. then 60%
Mental Health/Substance Abuse
Inpatient Ded. then 80% Ded. then 60% Ded. then 80% Ded. then 60%
Outpatient Ded. then 80% Ded. then 60% Ded. then 80% Ded. then 60%
Psychotherapy
oice visit $25 copay Ded. then 60% Ded. then 80% Ded. then 60%
Prescription Drugs (In-Network only)
Retail— 30-days
Supply Limit
Tier 1 $25 copay Deductible then 80%*
Tier 2 $50 copay Deductible then 80%*
Tier 3 $75 copay Deductible then 80%*
Tier 4—specialty 25%, $150 maximum copay Deductible then 80%*
Mail Order— 90-days
Supply Limit
Tier 1 $50 copay Deductible then 80%*
Tier 2 $100 copay Deductible then 80%*
Tier 3 $150 copay Deductible then 80%*
Tier 4—specialty 25%, $150 maximum copay Deductible then 80%*
* The Preventive Drug Program covers certain preventive drugs at 100% with the deductible
waived. For a list of preventive medication contact C.H.I. Human Resources.
Diagnostic work, lab tests, and x-rays performed in the oice visit setting are subject to the
deductible and coinsurance.
There is a penalty for failure to pre-certify services out-of-network.
This summary is a highlight of the beneit provisions and should not be relied upon as a complete
detailed representation of the plan.
4
