Page 4 - 2016 Enrollment
P. 4
Beneits Guide
Medical/Prescription
Medical Benefits
Medical coverage will remain with BlueCross BlueShield (BCBS) of Illinois. An additional PPO plan with a
$1,500 deductible will be offered effective January 1, 2016. The $750 deductible PPO plan and two HSA qualiied
high deductible health plans (HDHP) will continue to be offered as well. All beneits will remain the same.
Continued Plan Offering BCBS of IL
$3,000 Ded Qualiied $1,500 Ded Qualiied HDHP $1,500 Ded Traditional $750 Ded Traditional
HDHP PPO Plan PPO Plan
In-Network In-Network In-Network
Dependent Children covered up to age 26 regardless of marital, student, or dependency status
eligibility (to age 30 if military veteran and Illinois resident)
Lifetime maximum Unlimited
Embedded—no Embedded—no one Embedded—no
Calendar Year one individual must Not Embedded—family individual must meet one individual must
Deductible meet more than the ded applies if one or more more than the individual meet more than the
individual limit dependents are covered limit individual limit
Individual $3,000 $1,500 $1,500 $750
Family $6,000 $3,000 $3,000 $1,500
Out-of-Pocket Embedded—out-of- Not embedded—family out-of- Embedded-out-of-pocket Embedded—out-of-
Maximum pocket maximum pocket maximum applies if one maximum includes pocket maximum
includes deductible or more dependents are covered deductible, coinsurance, includes deductible,
and coinsurance out-of-pocket maximum includes and medical copays coinsurance, and
deductible, coinsurance, and medical copays
prescription drug copays
Individual $3,000 $2,500 $4,000 $3,000
Family $6,000 $5,000 $8,000 $6,000
Physician Ofice Visits
Primary care 100% after ded 90% after ded $25 copay* $20 copay*
Specialist 100% after ded 90% after ded $50 copay* $40 copay*
Urgent Care 100% after ded 90% after ded 80% after ded In-network: if billed as
ov: ov copay—if billed
as outpatient hospital:
ER copay
Out-of-network: 60%
after ded
Wellness/preventive Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Lab Services
Physicians ofice 100% after ded 90% after ded Covered at 100%** Covered at 100%**
Outpatient facility 100% after ded 90% after ded Covered at 100%** Covered at 100%**
Outpatient hospital 100% after ded 90% after ded Covered at 100%** Covered at 100%**
X-Ray/Radiology Services
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100 percent. 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 ded/coinsurance
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Medical/Prescription
Medical Benefits
Medical coverage will remain with BlueCross BlueShield (BCBS) of Illinois. An additional PPO plan with a
$1,500 deductible will be offered effective January 1, 2016. The $750 deductible PPO plan and two HSA qualiied
high deductible health plans (HDHP) will continue to be offered as well. All beneits will remain the same.
Continued Plan Offering BCBS of IL
$3,000 Ded Qualiied $1,500 Ded Qualiied HDHP $1,500 Ded Traditional $750 Ded Traditional
HDHP PPO Plan PPO Plan
In-Network In-Network In-Network
Dependent Children covered up to age 26 regardless of marital, student, or dependency status
eligibility (to age 30 if military veteran and Illinois resident)
Lifetime maximum Unlimited
Embedded—no Embedded—no one Embedded—no
Calendar Year one individual must Not Embedded—family individual must meet one individual must
Deductible meet more than the ded applies if one or more more than the individual meet more than the
individual limit dependents are covered limit individual limit
Individual $3,000 $1,500 $1,500 $750
Family $6,000 $3,000 $3,000 $1,500
Out-of-Pocket Embedded—out-of- Not embedded—family out-of- Embedded-out-of-pocket Embedded—out-of-
Maximum pocket maximum pocket maximum applies if one maximum includes pocket maximum
includes deductible or more dependents are covered deductible, coinsurance, includes deductible,
and coinsurance out-of-pocket maximum includes and medical copays coinsurance, and
deductible, coinsurance, and medical copays
prescription drug copays
Individual $3,000 $2,500 $4,000 $3,000
Family $6,000 $5,000 $8,000 $6,000
Physician Ofice Visits
Primary care 100% after ded 90% after ded $25 copay* $20 copay*
Specialist 100% after ded 90% after ded $50 copay* $40 copay*
Urgent Care 100% after ded 90% after ded 80% after ded In-network: if billed as
ov: ov copay—if billed
as outpatient hospital:
ER copay
Out-of-network: 60%
after ded
Wellness/preventive Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Lab Services
Physicians ofice 100% after ded 90% after ded Covered at 100%** Covered at 100%**
Outpatient facility 100% after ded 90% after ded Covered at 100%** Covered at 100%**
Outpatient hospital 100% after ded 90% after ded Covered at 100%** Covered at 100%**
X-Ray/Radiology Services
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100 percent. 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 ded/coinsurance
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