Page 16 - 2017 US Benefits Guide - for all Capgemni employees in the FS SBU
P. 16
Medical Plan Comparison Chart What’s an out-of-
pocket maximum?
Premier PPO Basic PPO The Medical Plan’s
Covered Health Services In-Network Out-of-Network 1 In-Network Out-of-Network 1 out-of-pocket maximum
Office Visit Co-pays is the total amount you
Wellness $0 50% after deductible $0 50% after deductible pay out of pocket
Primary Care Physician $20 50% after deductible $20 50% after deductible (including deductibles,
Specialist $30 50% after deductible $30 50% after deductible co-pays, co-insurance
MDLIVE Tele-visit $20 50% after deductible $20 50% after deductible and prescription co-pays)
in one plan year before
Medical Deductible the plan pays 100% of
You Only $300 $600 $600 $1,200 eligible expenses.
You + Spouse/Domestic Partner $600 $1,200 $1,200 $2,400
You + Child(ren) $600 $1,200 $1,200 $2,400 Save time and money
You + Family $600 $1,200 $1,200 $2,400 with MDLIVE.
Professional Services MDLIVE service gives
and Hospital Services you 24/7/365 access
(Co-insurance ) 85% after deductible 50% after deductible 75% after deductible 50% after deductible to a doctor through a
2
Inpatient Care 85% after deductible 50% after deductible 75% after deductible 50% after deductible phone call or web chat
Outpatient Care
for a $20 co-pay. You
Annual Out-of-Pocket can use MDLIVE for
Maximum routine illnesses like
You Only $3,150 $4,725 $4,500 $7,500 allergies, ear infections
You + Spouse/Domestic Partner $6,300 $9,450 $9,000 $15,000 and more. Go to
You + Child(ren) $6,300 $9,450 $9,000 $15,000 www.mdlive.com/bcbsil
You + Family $6,300 $9,450 $9,000 $15,000 for more information.
Lifetime Maximum Benefit 3 Unlimited Unlimited
Emergency Room $100 (waived if admitted) $100 (waived if admitted)
Urgent Care Co-pay $50 (waived if admitted) $50 (waived if admitted)
Continued on next page
1 Out-of-network beneits will be based on maximum allowance as determined by Blue Cross Blue Shield of Illinois.
2 You will be responsible for the irst $500 of covered services for failure to notify Blue Cross as required for Inpatient Hospital, Skilled Nursing
Facility, Coordinated Home Care Program, Private Duty Nursing Services, and Mental Health and Substance Abuse admissions.
3 Certain limitations apply to the Lifetime Maximum Beneit. Please see the Summary Plan Description for details.
Co-pays are not subject to deductible. The deductible must be met before co-insurance applies. Deductibles are met for the Plan Year when
(a) a covered member satisies the individual deductible maximum or (b) any combination of covered members satisies the family deductible
maximum. Out-of-pocket limits are met for the Plan Year when (a) a covered member satisies the individual out-of-pocket maximum or
(b) any combination of covered members satisies the family out-of-pocket maximum.
CAPGEMINI 2017 BENEFITS GUIDE 13
pocket maximum?
Premier PPO Basic PPO The Medical Plan’s
Covered Health Services In-Network Out-of-Network 1 In-Network Out-of-Network 1 out-of-pocket maximum
Office Visit Co-pays is the total amount you
Wellness $0 50% after deductible $0 50% after deductible pay out of pocket
Primary Care Physician $20 50% after deductible $20 50% after deductible (including deductibles,
Specialist $30 50% after deductible $30 50% after deductible co-pays, co-insurance
MDLIVE Tele-visit $20 50% after deductible $20 50% after deductible and prescription co-pays)
in one plan year before
Medical Deductible the plan pays 100% of
You Only $300 $600 $600 $1,200 eligible expenses.
You + Spouse/Domestic Partner $600 $1,200 $1,200 $2,400
You + Child(ren) $600 $1,200 $1,200 $2,400 Save time and money
You + Family $600 $1,200 $1,200 $2,400 with MDLIVE.
Professional Services MDLIVE service gives
and Hospital Services you 24/7/365 access
(Co-insurance ) 85% after deductible 50% after deductible 75% after deductible 50% after deductible to a doctor through a
2
Inpatient Care 85% after deductible 50% after deductible 75% after deductible 50% after deductible phone call or web chat
Outpatient Care
for a $20 co-pay. You
Annual Out-of-Pocket can use MDLIVE for
Maximum routine illnesses like
You Only $3,150 $4,725 $4,500 $7,500 allergies, ear infections
You + Spouse/Domestic Partner $6,300 $9,450 $9,000 $15,000 and more. Go to
You + Child(ren) $6,300 $9,450 $9,000 $15,000 www.mdlive.com/bcbsil
You + Family $6,300 $9,450 $9,000 $15,000 for more information.
Lifetime Maximum Benefit 3 Unlimited Unlimited
Emergency Room $100 (waived if admitted) $100 (waived if admitted)
Urgent Care Co-pay $50 (waived if admitted) $50 (waived if admitted)
Continued on next page
1 Out-of-network beneits will be based on maximum allowance as determined by Blue Cross Blue Shield of Illinois.
2 You will be responsible for the irst $500 of covered services for failure to notify Blue Cross as required for Inpatient Hospital, Skilled Nursing
Facility, Coordinated Home Care Program, Private Duty Nursing Services, and Mental Health and Substance Abuse admissions.
3 Certain limitations apply to the Lifetime Maximum Beneit. Please see the Summary Plan Description for details.
Co-pays are not subject to deductible. The deductible must be met before co-insurance applies. Deductibles are met for the Plan Year when
(a) a covered member satisies the individual deductible maximum or (b) any combination of covered members satisies the family deductible
maximum. Out-of-pocket limits are met for the Plan Year when (a) a covered member satisies the individual out-of-pocket maximum or
(b) any combination of covered members satisies the family out-of-pocket maximum.
CAPGEMINI 2017 BENEFITS GUIDE 13
