Page 14 - Demo

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Schedule of Benefits
FULL-TIME AND PART-TIME (30 OR OR MORE HOURS PER WEEK)
HMO HMO Illinois® & Blue Advantage HMOSM
HMO 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 $1 800/$12 700 (includes deductible) Penalty for Failure to Pre-Authorize
Not applicable
$500 Penalty for Failure to Call a a a 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 the the the member’s responsibility includes the the the the difference if if any between the the the the in-network payment allowance and the the the the provider’s charge **
Must contact a a a a a a a a a a a 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 at at copayment levels without satisfying the deductible