Page 6 - 2018 Peak Benefit Guide
P. 6
Medical Benefits
You have the option of choosing between one traditional PPO plan and one HSA qualiied high deductible
health plan (HDHP).
BCBS of IL BCBS of IL
$1,500 Ded PPO Copay Plan $3,000 Ded Qualiied HDHP
In-Network In-Network
Dependent Eligibility Children covered up to age 26 regardless of marital, student, or dependency status
Lifetime Maximum Unlimited
Calendar Year Deductible Embedded—no one individual must meet Embedded—no one individual must meet
more than the individual limit more than the individual limit
Individual $1,500 $3,000
Family $3,000 $6,000
Out-of-Pocket Maximum Embedded—out-of-pocket maximum Embedded—out-of-pocket maximum
includes deductible, coinsurance, and includes deductible and coinsurance
medical copays
Individual $4,000 $3,000
Family $8,000 $6,000
Physician Ofice Visits
Primary Care $25 copay* 100% after ded
Specialist $50 copay* 100% after ded
Urgent Care If billed as ofice visit, ofice visit copay; 100% after ded
otherwise 80% after ded
Wellness/Preventive Covered at 100% Covered at 100%
Lab Services
Physicians Ofice Covered at 100%** 100% after ded
Outpatient Facility Covered at 100%** 100% after ded
Outpatient Hospital Covered at 100%** 100% after ded
X-Ray/Radiology Services
Physicians Ofice Covered at 100%** 100% after ded
Outpatient Facility Covered at 100%** 100% after ded
Outpatient Hospital Covered at 100%* 100% after ded
Hospital Services
Inpatient 80% after ded 100% after ded
Outpatient 80% after ded 100% after ded
Emergency Room $250 copay 100% after ded
Ambulance 80% after ded 100% after ded
Mental Health
Inpatient 80% after ded 100% after ded
Limitations None None
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100%. All other services
are subject to ded/ coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans, etc.),
nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance
6 2018 Benefits Enrollment
You have the option of choosing between one traditional PPO plan and one HSA qualiied high deductible
health plan (HDHP).
BCBS of IL BCBS of IL
$1,500 Ded PPO Copay Plan $3,000 Ded Qualiied HDHP
In-Network In-Network
Dependent Eligibility Children covered up to age 26 regardless of marital, student, or dependency status
Lifetime Maximum Unlimited
Calendar Year Deductible Embedded—no one individual must meet Embedded—no one individual must meet
more than the individual limit more than the individual limit
Individual $1,500 $3,000
Family $3,000 $6,000
Out-of-Pocket Maximum Embedded—out-of-pocket maximum Embedded—out-of-pocket maximum
includes deductible, coinsurance, and includes deductible and coinsurance
medical copays
Individual $4,000 $3,000
Family $8,000 $6,000
Physician Ofice Visits
Primary Care $25 copay* 100% after ded
Specialist $50 copay* 100% after ded
Urgent Care If billed as ofice visit, ofice visit copay; 100% after ded
otherwise 80% after ded
Wellness/Preventive Covered at 100% Covered at 100%
Lab Services
Physicians Ofice Covered at 100%** 100% after ded
Outpatient Facility Covered at 100%** 100% after ded
Outpatient Hospital Covered at 100%** 100% after ded
X-Ray/Radiology Services
Physicians Ofice Covered at 100%** 100% after ded
Outpatient Facility Covered at 100%** 100% after ded
Outpatient Hospital Covered at 100%* 100% after ded
Hospital Services
Inpatient 80% after ded 100% after ded
Outpatient 80% after ded 100% after ded
Emergency Room $250 copay 100% after ded
Ambulance 80% after ded 100% after ded
Mental Health
Inpatient 80% after ded 100% after ded
Limitations None None
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100%. All other services
are subject to ded/ coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans, etc.),
nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance
6 2018 Benefits Enrollment
