Page 7 - 2018 Peak Benefit Guide

BCBS of IL BCBS of IL
$1,500 Ded PPO Copay Plan $3,000 Ded Qualiied HDHP
In-Network In-Network
Outpatient—Ofice Visit $25 copay 100% after ded
Limitations None None
Substance Abuse
Inpatient 80% after ded 100% after ded
Limitations None None
Outpatient—Ofice Visits $25 copay 100% after ded
Limitations None None
Other
Skilled Nursing Care 80% after ded 100% after ded
(no limits)
Home Healthcare (no limits) 80% after ded 100% after ded
Hospice Care 80% after ded 100% after ded
Durable Medical Equipment 80% after ded 100% after ded
Prosthetic Devices 80% after ded 100% after ded
Chiropractic Care—30 visits
$25 copay 100% after ded
Outpatient Therapies
Physical Therapy $25 copay 100% after ded
Limitations No limits No limits
Speech Therapy $25 copay 100% after ded
Limitations No limits No limits
Occupational Therapy $25 copay 100% after ded
Limitations No limits No limits
Transplants (Some transplants must be performed in hospitals with approved BCBS Human Organ Transplant programs)
80% after ded 100% after ded

For out-of-network coverage details, please refer to your summary plan description (SPD) or an oficial plan

document.

Peak-Ryzex 7