Page 10 - Dentons 2021 Benefits Guide Retiree
P. 10
BCBSIL
Plan Feature CDHP 3000 CDHP 1500 PPO 1200
Out-of- Out-of- Out-of-
In-Network Network In-Network Network In-Network Network
Provider Network Blue Cross Blue Shield’s National PPO Network
HSA Compatible Yes Yes No
Annual Deductible
Individual $3,000 $6,000 $1,500 $3,500 $1,200 $3,000
Family $5,000 2 $10,000 $3,000 2 $7,000 $3,000 1 $6,000
Annual Out-of-Pocket Maximum
Individual $5,000 $10,000 $3,000 $6,000 $3,200 $6,000
Family $10,000 1 $20,000 $6,000 2 $12,000 $6,400 1 $12,000
Coinsurance
Your Responsibility 20% after 40% after 20% after 40% after 20% after 40% after
deductible deductible deductible deductible deductible deductible
In-Network Office Visit and Pharmacy
Preventive Care 3 100% 40% after 100% 40% after 100% 40% after
deductible deductible deductible
Physician’s Services
Primary Care 20% after 40% after 20% after 40% after $30 copay 40% after
Physician — Your deductible deductible deductible deductible deductible
Responsibility
Specialist Office 20% after 40% after 20% after 40% after $50 copay 40% after
Visit — Your deductible deductible deductible deductible deductible
Responsibility
Emergency Care Services
Urgent Care Center — 20% after 40% after 20% after 40% after $50 copay 40% after
Your Responsibility deductible deductible deductible deductible deductible
Emergency Room — 20% after 20% after 20% after 20% after $150 $150
Your Responsibility deductible deductible deductible deductible copay, 20% copay, 20%
coinsurance coinsurance
Inpatient Medical Services
Your Responsibility 20% after 40% after 20% after 40% after 20% after 40% after
deductible deductible deductible deductible deductible deductible
Vision Coverage
Routine Exam 4 100% 100% 100% 100% 100% 100%
Pharmacy Services (excludes CVS)
Generic/Brand/Non- 20% after 20% after After After $10/$40/ $10/$40/
Formulary deductible deductible 3 deductible: deductible: $80 $80 3
$10/$40/$80 $10/$40
/$80 3
1 Each each family member must meet his/her own individual deductible or out-of-pocket maximum until the total family
coverage is met.
2 The overall family deductible or out of pocket maximum must be satisfied by one or more enrollees before the coverage
requirement is met.
3 For out-of-network drug provider, member is responsible for 25% of the eligible amount after the copay.
4 Usual and Customary Fee — fees as a reasonably determine by BCBS IL. Most in-network providers charge Usual and
Customary rates, but please confirm with BCBS IL customer service.
What do out-of-network benefits really cost?
In determining out-of-network coverage, insurance carriers will pay claims according to the
Schedule of Benefits. However, the “allowed charges” are based on the cost for services established
by Medicare. Members are then responsible for any remaining balance owed to the provider. These
remaining amounts do not count toward deductible or out-of-pocket accumulators.
10
Plan Feature CDHP 3000 CDHP 1500 PPO 1200
Out-of- Out-of- Out-of-
In-Network Network In-Network Network In-Network Network
Provider Network Blue Cross Blue Shield’s National PPO Network
HSA Compatible Yes Yes No
Annual Deductible
Individual $3,000 $6,000 $1,500 $3,500 $1,200 $3,000
Family $5,000 2 $10,000 $3,000 2 $7,000 $3,000 1 $6,000
Annual Out-of-Pocket Maximum
Individual $5,000 $10,000 $3,000 $6,000 $3,200 $6,000
Family $10,000 1 $20,000 $6,000 2 $12,000 $6,400 1 $12,000
Coinsurance
Your Responsibility 20% after 40% after 20% after 40% after 20% after 40% after
deductible deductible deductible deductible deductible deductible
In-Network Office Visit and Pharmacy
Preventive Care 3 100% 40% after 100% 40% after 100% 40% after
deductible deductible deductible
Physician’s Services
Primary Care 20% after 40% after 20% after 40% after $30 copay 40% after
Physician — Your deductible deductible deductible deductible deductible
Responsibility
Specialist Office 20% after 40% after 20% after 40% after $50 copay 40% after
Visit — Your deductible deductible deductible deductible deductible
Responsibility
Emergency Care Services
Urgent Care Center — 20% after 40% after 20% after 40% after $50 copay 40% after
Your Responsibility deductible deductible deductible deductible deductible
Emergency Room — 20% after 20% after 20% after 20% after $150 $150
Your Responsibility deductible deductible deductible deductible copay, 20% copay, 20%
coinsurance coinsurance
Inpatient Medical Services
Your Responsibility 20% after 40% after 20% after 40% after 20% after 40% after
deductible deductible deductible deductible deductible deductible
Vision Coverage
Routine Exam 4 100% 100% 100% 100% 100% 100%
Pharmacy Services (excludes CVS)
Generic/Brand/Non- 20% after 20% after After After $10/$40/ $10/$40/
Formulary deductible deductible 3 deductible: deductible: $80 $80 3
$10/$40/$80 $10/$40
/$80 3
1 Each each family member must meet his/her own individual deductible or out-of-pocket maximum until the total family
coverage is met.
2 The overall family deductible or out of pocket maximum must be satisfied by one or more enrollees before the coverage
requirement is met.
3 For out-of-network drug provider, member is responsible for 25% of the eligible amount after the copay.
4 Usual and Customary Fee — fees as a reasonably determine by BCBS IL. Most in-network providers charge Usual and
Customary rates, but please confirm with BCBS IL customer service.
What do out-of-network benefits really cost?
In determining out-of-network coverage, insurance carriers will pay claims according to the
Schedule of Benefits. However, the “allowed charges” are based on the cost for services established
by Medicare. Members are then responsible for any remaining balance owed to the provider. These
remaining amounts do not count toward deductible or out-of-pocket accumulators.
10
