Page 6 - 2016 Enrollment
P. 6
Beneits Guide
Continued Plan Offering BCBS of IL
$3,000 Ded Qualiied $1,500 Ded Traditional $750 Ded Traditional
HDHP $1,500 Ded Qualiied HDHP PPO Plan PPO Plan
In-Network In-Network In-Network
Prescription Drugs
Ded Medical ded Medical ded None None
Out-of-pocket Rx included in medical Rx included in medical OOP on Separate Rx Separate Rx
maximum (OOP) OOP on previous page previous page OOP of $500 per OOP of $500 per
individual/$1,000 per individual/$1,000 per
family family
Step therapy Applies Applies Applies Applies
Retail
Tier 1 100% after ded $10 copay, after deductible $10 copay $10 copay
Tier 2 100% after ded $30 copay, after deductible $40 copay $30 copay
Tier 3 100% after ded $50 copay, after deductible $70 copay $50 copay
Mail Order
Mandatory mail NA NA NA NA
order
Tier 1 100% after ded $25 copay, after deductible $25 copay $25 copay
Tier 2 100% after ded $75 copay, after deductible $75 copay $75 copay
Tier 3 100% after ded $125 copay, after deductible $125 copay $125 copay
* BCBS pays 75 percent of the amount you would have received had you used a network provider
BlueCross BlueShield Member Site
This document is intended to merely
highlight or summarize certain aspects The BCBS member site, Blue Access for members
of the employer’s beneit program(s). (www.bcbsil.com/member) offers many valuable services including the
It is not a summary plan description following.
(SPD) or an oficial plan document.
Your rights and obligations under Provider and pharmacy Information regarding paid and
the program(s) are set forth in the searches pending claims
oficial plan documents. All statements
in this summary are subject to the Prescription drug formulary Health and wellness
terms of the oficial plan documents, Access to temporary ID cards information
as interpreted by the appropriate
plan iduciary. In the case of an and means to order another ID
ambiguity or outright conlict between card
a provision in this summary and a
provision in the plan documents, the You can search for participating providers on the BCBS site,
terms of the plan documents control. www.bcbsil.com. Complete the following steps.
The employer reserves the right to
review, change, or terminate the 1. Go to www.bcbsil.com 4. Choose “PPO (Participating
plan, or any beneits under it, for any 2. Click on “Find a Doctor” on Provider Options) for Network
reason. Type”
the left side of the screen
3. Click “Provider Finder”, then 5. Enter additional search criteria
select the state in which you live
6
Continued Plan Offering BCBS of IL
$3,000 Ded Qualiied $1,500 Ded Traditional $750 Ded Traditional
HDHP $1,500 Ded Qualiied HDHP PPO Plan PPO Plan
In-Network In-Network In-Network
Prescription Drugs
Ded Medical ded Medical ded None None
Out-of-pocket Rx included in medical Rx included in medical OOP on Separate Rx Separate Rx
maximum (OOP) OOP on previous page previous page OOP of $500 per OOP of $500 per
individual/$1,000 per individual/$1,000 per
family family
Step therapy Applies Applies Applies Applies
Retail
Tier 1 100% after ded $10 copay, after deductible $10 copay $10 copay
Tier 2 100% after ded $30 copay, after deductible $40 copay $30 copay
Tier 3 100% after ded $50 copay, after deductible $70 copay $50 copay
Mail Order
Mandatory mail NA NA NA NA
order
Tier 1 100% after ded $25 copay, after deductible $25 copay $25 copay
Tier 2 100% after ded $75 copay, after deductible $75 copay $75 copay
Tier 3 100% after ded $125 copay, after deductible $125 copay $125 copay
* BCBS pays 75 percent of the amount you would have received had you used a network provider
BlueCross BlueShield Member Site
This document is intended to merely
highlight or summarize certain aspects The BCBS member site, Blue Access for members
of the employer’s beneit program(s). (www.bcbsil.com/member) offers many valuable services including the
It is not a summary plan description following.
(SPD) or an oficial plan document.
Your rights and obligations under Provider and pharmacy Information regarding paid and
the program(s) are set forth in the searches pending claims
oficial plan documents. All statements
in this summary are subject to the Prescription drug formulary Health and wellness
terms of the oficial plan documents, Access to temporary ID cards information
as interpreted by the appropriate
plan iduciary. In the case of an and means to order another ID
ambiguity or outright conlict between card
a provision in this summary and a
provision in the plan documents, the You can search for participating providers on the BCBS site,
terms of the plan documents control. www.bcbsil.com. Complete the following steps.
The employer reserves the right to
review, change, or terminate the 1. Go to www.bcbsil.com 4. Choose “PPO (Participating
plan, or any beneits under it, for any 2. Click on “Find a Doctor” on Provider Options) for Network
reason. Type”
the left side of the screen
3. Click “Provider Finder”, then 5. Enter additional search criteria
select the state in which you live
6
