Page 7 - 2018 Movilitas Benefit Guide

BCBS of IL BCBS of IL BCBS of IL
$750 Ded PPO Copay Plan $1,500 Ded PPO Copay Plan $3,000 Ded Qualiied HDHP
In-Network In-Network In-Network
Mental Health
Inpatient 80% after ded 90% after ded 100% after ded
Limitations None None None
Outpatient—Ofice Visit 80% after ded 90% after ded 100% after ded
Limitations None None None
Substance Abuse
Inpatient 80% after ded 90% after ded 100% after ded
Limitations None None None
Outpatient—Ofice Visits 80% after ded 90% after ded 100% after ded
Limitations None None None
Other
Skilled Nursing Care 80% after ded 80% after ded 100% after ded
(no limits)
Home Healthcare (no limits) 80% after ded 80% after ded 100% after ded
Hospice Care 80% after ded 80% after ded 100% after ded
Durable Medical Equipment 80% after ded 80% after ded 100% after ded
Prosthetic Devices 80% after ded 80% after ded 100% after ded
Chiropractic Care—30 visits
$20 copay $25 copay 100% after ded
Outpatient Therapies
Physical Therapy $20 copay $25 copay 100% after ded
Limitations No limits No limits No limits
Speech Therapy $20 copay $25 copay 100% after ded
Limitations No limits No limits No limits
Occupational Therapy $20 copay $25 copay 100% after ded
Limitations No limits No limits No limits
Transplants (Some transplants must be performed in hospitals with approved BCBS Human Organ Transplant programs)
80% after ded 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.

Movilitas 7