Page 8 - Adreima Enrollment Guide
P. 8
Annual Enrollment
Medical Benefits
Traditional PPO CDHP
PPO Out-of-Network PPO Out-of-Network
Lifetime Maximum Unlimited Unlimited
Calendar Year Ded .
Individual $1,500 $3,000 $2,500 $4,500
Family $3,000 $6,000 $5,000 $9,000
Out-of-Pocket Maximum
Individual (includes ded) $6,000 $12,000 $3,500 $5,500
Family (includes ded) $12,000 $24,000 $7,000 $11,000
Physician Ofice Visits
Primary care $30 copay 40% after ded . 10% after ded . 30% after ded .
Specialist $50 copay 40% after ded . 10% after ded . 30% after ded .
Urgent care $75 copay 40% after ded . 10% after ded . 30% after ded .
Wellness/preventive 100% covered 40% after ded . 100% covered 30% after ded .
Lab Services
Outpatient facility 100% covered 40% after ded . 10% after ded . 30% after ded .
Outpatient hospital 100% covered 40% after ded . 10% after ded . 30% after ded .
X-Ray/Radiology Services
Outpatient facility 100% covered 40% after ded . 10% after ded . 30% after ded .
Outpatient hospital 100% covered 40% after ded . 10% after ded . 30% after ded .
Hospital Services
Inpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Outpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Emergency room $200 copay $200 copay 10% after ded . 30% after ded .
Mental Health
Inpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Outpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Substance Abuse
Inpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Outpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Prescription drugs Pharmacy copay applies after ded . is met;
Pharmacy is paid at 100% after OOP maximum is
met
Retail—Supply Limit (34 Days)
Tier 1 $10 copay $10 copay * $10 copay $10 copay *
Tier 2 $30 copay $30 copay * $30 copay $30 copay *
Tier 3 $50 copay $50 copay * $50 copay $50 copay *
Mail Order—Supply Limit (90 Days)
Tier 1 $20 copay N/A $25 copay N/A
Tier 2 $60 copay $75 copay
Tier 3 $100 copay $125 copay
* Copay, then 25 percent of eligible amount
Coinsurance percentages above relect what you pay as a member once you have met your deductible. BCBSIL covers the rest of the cost.
Note: under the CDHP, a family member must satisfy the full family deductible before coinsurance will apply . This is different from the High and Low
plans where each family member only needs to satisfy the individual deductible (up to the family maximum) before coinsurance applies .
8
Medical Benefits
Traditional PPO CDHP
PPO Out-of-Network PPO Out-of-Network
Lifetime Maximum Unlimited Unlimited
Calendar Year Ded .
Individual $1,500 $3,000 $2,500 $4,500
Family $3,000 $6,000 $5,000 $9,000
Out-of-Pocket Maximum
Individual (includes ded) $6,000 $12,000 $3,500 $5,500
Family (includes ded) $12,000 $24,000 $7,000 $11,000
Physician Ofice Visits
Primary care $30 copay 40% after ded . 10% after ded . 30% after ded .
Specialist $50 copay 40% after ded . 10% after ded . 30% after ded .
Urgent care $75 copay 40% after ded . 10% after ded . 30% after ded .
Wellness/preventive 100% covered 40% after ded . 100% covered 30% after ded .
Lab Services
Outpatient facility 100% covered 40% after ded . 10% after ded . 30% after ded .
Outpatient hospital 100% covered 40% after ded . 10% after ded . 30% after ded .
X-Ray/Radiology Services
Outpatient facility 100% covered 40% after ded . 10% after ded . 30% after ded .
Outpatient hospital 100% covered 40% after ded . 10% after ded . 30% after ded .
Hospital Services
Inpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Outpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Emergency room $200 copay $200 copay 10% after ded . 30% after ded .
Mental Health
Inpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Outpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Substance Abuse
Inpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Outpatient 20% after ded . 40% after ded . 10% after ded . 30% after ded .
Prescription drugs Pharmacy copay applies after ded . is met;
Pharmacy is paid at 100% after OOP maximum is
met
Retail—Supply Limit (34 Days)
Tier 1 $10 copay $10 copay * $10 copay $10 copay *
Tier 2 $30 copay $30 copay * $30 copay $30 copay *
Tier 3 $50 copay $50 copay * $50 copay $50 copay *
Mail Order—Supply Limit (90 Days)
Tier 1 $20 copay N/A $25 copay N/A
Tier 2 $60 copay $75 copay
Tier 3 $100 copay $125 copay
* Copay, then 25 percent of eligible amount
Coinsurance percentages above relect what you pay as a member once you have met your deductible. BCBSIL covers the rest of the cost.
Note: under the CDHP, a family member must satisfy the full family deductible before coinsurance will apply . This is different from the High and Low
plans where each family member only needs to satisfy the individual deductible (up to the family maximum) before coinsurance applies .
8
