Page 6 - 2022 US Benefits Guide FINAL

BLUE CROSS BLUE SHIELD IL (BCBSIL)

MEDICAL AND PHARMACY COVERAGE

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HDHP PPO
Medical Plan Provisions In-Network Out-of-Network In-Network Out-of-Network

Semi Annual Company $750 / $1,250
contribution to HSA Contributions made on 1/15 and 7/15 Not Applicable
(Individual/Family)

Annual Deductible $2,800 / $5,600 $5,000 / $10,000 $500 / $1,500 $1,000 / $3,000
(Individual/Family)

Out-of-Pocket Maximum
$4,000 / $9,500 $10,000 / $20,000 $3,500 / $8,750 $10,000 / $20,000
(Includes Deductible)
Preventive Care Covered at 100% 60% * Covered at 100% 60% *

Primary Care Provider 80%* 60%* $25 copay 60%*
Office Visit
Specialist Office Visit 80%* 60%* $50 copay 60%*
X-Ray and Lab 80%* 60%* 80%* 60%*

60%* after separate 60%* after separate
Inpatient Hospital Services 80%* 80%*
$300 deductible $200 deductible

Outpatient Hospital Services 80%* 60%* 80%* 60%*

Urgent Care 80%* 60%* 80%* 60%*
$200 Copay 1 - 3 Visits, $400 Copay 4-6 Visits,
Emergency Room 80%*
$600 Copay 7+ Visits

Pharmacy Provisions In-Network Out-of-Network In-Network Out-of-Network

Retail pharmacy (up to a 30-day supply)

Generic $15 Copay* Not Covered $15 Copay Not Covered

Brand Preferred $45 Copay* Not Covered $45 Copay Not Covered

Brand Non-Preferred $75 Copay* Not Covered $75 Copay Not Covered

Specialty $150 Copay* Not Covered $150 Copay Not Covered

Mail Order Pharmacy (90-day supply)
Generic $30 Copay* Not Covered $30 Copay Not Covered

Brand Preferred $90 Copay* Not Covered $90 Copay Not Covered

Brand Non-Preferred $150 Copay* Not Covered $150 Copay Not Covered

Specialty Not Available Not Covered Not Available Not Covered
*After Deductible

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