Page 9 - Dentons 2021 Benefits Guide Mainland

2021

Dentons Benefits Guide

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
100% 40% after 100% 40% after 100% 40% after
Preventive Care 3
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%
4
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.

Participate in the Wellness for Life program and save up to
$480 per year off your premiums!

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