Page 14 - HCSC2019EG

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Schedule of Benefits
FULL-TIME AND PART-TIME (30 OR MORE HOURS PER WEEK)
HMO Illinois® & Blue Advantage HMOSM
HMO Blue TexasSM & HMO-NM, OK
Coverage
HMO Network Only
HMO Network Only
Health Savings Account
Individual/Family
Not applicable
Not applicable
Calendar Year Deductible
Individual/ Family
$500/$1,000
$500/$1,000
Out-of-Pocket Maximum
(includes deductible) Individual/ Family
$1,500/$3,000
$1,800/$12,700 (includes deductible)
Penalty for Failure to Pre-Authorize
Not applicable
$500
Penalty for Failure to Call a Health Advocate**
$0
$0
Lifetime Health Care Maximum
Unlimited
Unlimited
Physician Services –You Pay
Office Visit
Non-Specialist/Specialist
$25/$40 copay per visit
$25/$40 copay per visit
Virtual Visits
Not applicable
Not applicable
Chiropractic & Muscle Manipulation
$25 copay no maximum
$25 copay no maximum
Physical Therapy
No copay; limited to 60 visits combined
$40 copay; 60 visits combined for speech and physical therapy
Preventive Services
Non-Specialist/Specialist
$0, no deductible
$0, no deductible
Well-Baby Care
Non-Specialist/Specialist
$0 copay per visit
$0 copay per visit
Immunizations
Non-Specialist/Specialist
$0, no deductible
$0, no deductible
Diagnostic X-ray and Lab
Non-Specialist/Specialist
$0, no deductible
10% after deductible
* In addition to coinsurance, the member’s responsibility includes the difference, if any, between the in-network payment allowance and the provider’s charge.
** Must contact a health advocate prior to scheduling imaging & CT scans, x-rays, joint replacement, bariatric surgery, musculoskeletal IP/OP procedures, breast reductions (medically necessary).
*** Certain preventive medications are available at copayment levels without satisfying the deductible.