GENERAL PROVISIONS Web Site Address Find a Plan Doctor or Facility Health Plan Telephone Number NCQA Accreditation Status http://www.bcbsil.com The HMO provider network is available by clicking on this website address: Plan Provider Directory Search<b/> 800-892-2803 Commendable US News RATINGS (Quality Report) Consumer Assessment Prevention Treatment ANNUAL OUT-O F-POCKET LIMITATION Single Contract Multiple Party None None WebMD Benefits 2009 Page 1 of 7
ANNUAL OUT-O F-POCKET LIMITATION Contract HOSPITAL Semi - Private Room and Board Surgery, Inpatient and Outpatient Physician Inpatient Physical Therapy Functional Occupational Therapy OUTPATIENT Office Visits (Including Urgent Care) Physical Exams Active Employees - $25 copay Retiree - $10 copay Active Employees - $25 copay Retiree - $10 copay WebMD Benefits 2009 Page 2 of 7
OUTPATIENT Well-Baby Care Immunizations Allergy Tests, Injections Diagnostic Lab Outpatient Physical Therapy X-Ray & Imaging Active Employees - $25 copay Retiree - $10 copay Active Employees - $25 copay (if involves office visit) Retiree - $10 copay (if involves office visit) Active Employees - $25 copay (if involves office visit) Retiree - $10 copay (if involves office visit) 60 treatments per condition, per calendar year MATERNITY Prenatal, Delivery and Postnatal ; $10 copay on first office visit only EMERGENCY Emergency Care Active Employees - $100 copay (waived if admitted) Retiree - covered WebMD Benefits 2009 Page 3 of 7
AMBULANCE Ambulance EXTENDED FACILITIES Skilled Nursing Facility Home Health Care Private Duty Nursing PSYCHIATRIC Hospital Outpatient 45 days, renewable after 60 days Active: $25 co-pay, Retirees: $10 co-pay, 20 visits per calendar year SUBSTANCE ABUSE Hospital Outpatient 45 days, renewable after 60 days Active: $25 co-pay, Retirees: $10 co-pay, 35 visits per calendar year WebMD Benefits 2009 Page 4 of 7
PRESCRIPTION DRUGS Retail Pharmacies Mail Order Program HEARING Audiometric Examination Hearing Aid Frequency Limitation Active: $5 generic/$11 brand name copay per prescription Retiree: $5 generic/$10 brand name copay per prescription See Footnote #1 Active:$10 generic/$22 brand name copay per prescription, up to a 90 day supply. Retiree: $10 generic/$20 brand name copay per prescription See Footnote #2 ; $10 office visit copay 36 months w/hearing Aid VISION Vision Care Contact Information Examination Lenses and Frames 800-892-2803, http://www.bcbsil.com Active: ; $25 office visit copay Retiree: ; $10 office visit copay Standard plastic lenses ; $110 retail allowance for any frame and 20% discount off balance over allowance WebMD Benefits 2009 Page 5 of 7
VISION Contact Lenses $55 maximum allowance FOOT AND ANKLE Foot and Ankle Care - Outpatient Contact your plan for details on covered services OTHER Durable Medical Equipment Prosthetic and Orthotic Appliances Health Education & Special Programs SPECIAL SITUATIONS When Enrolled in Medicare Sponsored Dependent Coverage Plan coordinates with Medicare Available at subscriber's expense WebMD Benefits 2009 Page 6 of 7
#1: A Surviving Spouse with a retirement date prior to 1/1/04 has a $0 copay per prescription. #2: A Surviving Spouse with a retirement date prior to 1/1/04 has a $0 copay per prescription, up to a 90 day supply WebMD Benefits 2009 Page 7 of 7