Page 2 - 2015 Benefits Guide

OPEN ENROLLMENT 2015

Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Illinois
Buy-Up Plan Basic Plan
1/1/2015 1/1/2015
Out-of-
Out-of-
Greenville PPO Network Greenville PPO Network
Lifetime maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited
Calendar Year Deductible
Individual $500 $1,000 $2,000 $1,000 $2,000 $3,000
Family $1,000 $2,000 $4,000 $2,000 $3,000 $6,000
Out-of-Pocket Includes Includes Includes Includes Includes Includes
Maximum Deductible Deductible Deductible Deductible Deductible Deductible
Individual $3,500 $5,000 $8,000 $4,000 $6,000 $9,000
Family $10,000 $12,700 $22,000 $11,000 $12,700 $24,000
Physician Ofice Visits
Primary Care $20 copay 80% after 60% after $25 copay 80% after 50% after
deductible deductible deductible deductible
Specialist $30 copay 80% after 60% after $50 copay 80% after 50% after
deductible deductible deductible deductible
Wellness/Preventive
Annual Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited
Immunizations 100% 100% 60% after 100% 100% 50% after
deductible deductible
Physical Exams 100% 100% 60% after 100% 100% 50% after
deductible deductible
Well-Woman and 100% 100% 60% after 100% 100% 50% after
Well-Man Exams deductible deductible
Physical Therapy
5 Visit Limit 100% after 80% after 60% after 100% after 80% after 60% after
deductible deductible deductible deductible deductible deductible
Hospital Services
Inpatient/Outpatient 100% after 80% after 60% after 100% after 80% after 50% after
deductible deductible deductible deductible deductible deductible
Emergency Room $300 copay; $300 copay; $300 copay; $300 copay; $300 copay; $300 copay;
80% 80% 80% 80% 80% 80%
Chiropractic Care
Not covered 80% after 60% after Not covered 80% after 50% after
deductible deductible deductible deductible
Limitations 5 visits per 5 visits per 5 visits per 5 visits per
calendar year calendar year calendar year calendar year

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