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Plan Type PPO
Office Visit for Primary Doctor
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No Charge
Office Visit for Specialist No Charge
Office Visit for Other Practitioner (Nurse, Physician Assistant) No Charge
Annual Deductible None
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 0%
Retail Prescription Drugs Generic Drugs: No Charge
Brand Name Drugs: No Charge
Non-Formulary Drugs: No Charge
Specialty Drugs: No Charge
Annual Out-of-Pocket Limit $0
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. This Plan does not cover any services and/or supplies provided to a Member outside the United States if the Member traveled to the location for the purposes of receiving medical services, supplies, or drugs. 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room No Charge
Emergency Ambulance Services No Charge
Urgent Care Facility No Charge
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: No Charge
Brand Name Drugs: No Charge
Non-Formulary Drugs: No Charge
Specialty Drugs: No Charge
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs Generic Drugs: No Charge
Brand Name Drugs: No Charge
Non-Formulary Drugs: No Charge
Specialty Drugs: No Charge
Mail Order Supply 90 days supply
Outpatient Coverage
Outpatient Surgery No Charge
Outpatient Lab/X-Ray No Charge
Imaging (CT and PET scans, MRIs) No Charge
Outpatient Mental Health No Charge
Outpatient Substance Abuse No Charge
Outpatient Rehabilitation Services (PT, OT, ST) No Charge
Inpatient Coverage
Hospitalization No Charge
Skilled Nursing Facility No Charge
Inpatient Mental Health No Charge
Inpatient Substance Abuse No Charge
Home Healthcare No Charge
Maternity Coverage
Pre & Postnatal Office Visit No Charge
Labor & Delivery Hospital Stay No Charge
Pediatric Services
Dental Checkup for Children No Charge
Vision Screening for Children No Charge, 1 Visit(s) per Year
Eye Glasses for Children No Charge, 1 Item(s) per Year
Major Dental Coverage (Pediatric) No Charge
Additional Coverage
Chiropractic Coverage No Charge, 25 Visit(s) per Year
Durable Medical Equipment No Charge
Hospice No Charge
Major Dental Coverage (Adult) No Charge
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required Yes
Out-of-Network Annual Deductible $12000/$25400
Out-of-Network Annual Coinsurance 20% Coinsurance after deductible
Out-of-Network Annual Out-of-Pocket Limit $12000/$25400
Additional Information
A.M. Best Rating A+ as of 12/19/2013
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Summary of Benefits & Coverage

The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

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Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage form pertains to the coverage provided by a particular health insurance plan. If you select certain optional benefits while applying for this health insurance plan, a modified Summary of Benefits & Coverage may be available that reflects the optional benefits that you selected. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • Blue Cross and Blue Shield of Illinois - A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
  • Blue Cross and Blue Shield of Illinois - Medical expense coverage will not be available until the effective date of the health contract and payment in full of the first month's premium. Applications must be received by Blue Cross and Blue Shield of Illinois within the defined enrollment period to be accepted. Effective dates for major medical coverage are available on the 1st of the month only, unless otherwise required by law. This effective date rule does not apply to temporary plans.