Page 15 - Demo

Schedule of Benefits
13
FULL-TIME AND PART-TIME (30 OR OR MORE HOURS PER WEEK)
HMO HMO Illinois & Blue Advantage HMO HMO HMO HMO Blue Texas & HMO-NM OK
Coverage
HMO Network Only
HMO Network Only
Surgery (Outpatient Hospital)
$0
10% after deductible Inpatient Physician Service $0
10% after deductible Inpatient Hospital Expenses
10% after deductible 10% after deductible Outpatient Surgery 10% after deductible 10% after deductible Outpatient Diagnostic X-ray and Lab
$0
10% no deductible Emergency Room
$200 copay per visit
($200 waived if admitted)
$200 copay per visit
($200 waived if admitted)
Prescriptions –You Pay
Retail Pharmacy Care Generic/Preferred/Non-Preferred
(30 day day supply 90-day retail available) /Specialty
$20/$50/$75/$100
$20/$50/$75/$100
Home Delivery
Generic/Preferred/Non-Preferred
(90 day supply)
$40/$100/$150
$40/$100/$150
Behavioral Health (BH) and Substance Abuse – You Pay
Inpatient BH (Hospital)
10% after deductible 10% after deductible Outpatient Counseling (Professional)
$25 copay $25 copay Substance Abuse (Professional)
10% after deductible 10% after deductible Substance Abuse (Outpatient)
$25 copay $25 copay * 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