Health insurance plans & prices _ HealthCare.pdf

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Peoplecovered:Primary(Age24) EDIT
2017 heal th insura nce plans & prices
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: Deductible : $7,150:: : IndividualTotal
Out-of-pocket maximum : $7,150
: :: Ind ividualTotal
Estimated monthly premium
$281.51
Deductible
$7,150
IndividualTotal
Out-of-pocket maximum
$7,150
IndividualTotal
Blue Cross And Blue Shiel d Of Illinois Blue Choice Preferred
Security PPO 100 ()
CatastrophicPPONationalProviderNetwork|PlanID:36096IL0990019
Copayments / Coinsurance
Emergencyroomcare:NoCha rgeAfterDeductible
Genericdrugs:NoCharg eAfterDeductible
Primarydoctor:$50
Specialistdoctor:NoCha rgeAfterDeductible
Doctors, facilities & drugs covered
DOCUMENTS
SummaryofBenefits
Planbrochure
Providerdirectory
Costsformedicalcare
()
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Primary care doctor visit
Limitsandexclusionsapply
: InNetwork:$50
: OutofNetwork:50%Coinsuranceafterdeductible
Specialist visit : InNetwork:NoChargeAfterDeductible
: OutofNetwork:50%Coinsuranceafterdeductible
X-rays and diagnostic imaging
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:50%Coinsuranceafterdeductible
Laboratory and outpatient professional services
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:50%Coinsuranceafterdeductible
Outpatient facility
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:50%Coinsuranceafterdeductible
Outpatient professional services : InNetwork:NoChargeAfterDeductible
: OutofNetwork:50%Coinsuranceafterdeductible
Hearing aids
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:50%Coinsuranceafterdeductible
Routine eye exam for adults : InNetwork:BenefitNotCovered
Routine eye exam for children
Limitsandexclusionsapply
: InNetwork:NoCharge
: OutofNetwork:BenefitNotCovered
Eyeglasses for children
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:BenefitNotCovered
Generic drugs
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:NoChargeAfterDeductible
Preferred brand drugs
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:NoChargeAfterDeductible
Non-preferred brand drugs
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:NoChargeAfterDeductible
Specialty drugs
Limitsandexclusionsapply
: InNetwork:NoChargeAfterDeductible
: OutofNetwork:50%
EligibleforHea lthSavingsAccount(HSA) : No
Prescriptiondrugcoverage
Listofcovereddrugs : View
Threemonthinne tworkmailorderph armacybenefi t : Yes
Prescriptiondrugdeductible  : Includedinplandeductible
Prescriptiondrugoutofpocketmaximum
:
Includedinplan'soutofpocketmaximum
Accesstodoctorsandhospitals
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Emergency room care : InNetwork:NoChargeAfterDeductible
: OutofNetwork:NoChargeAfterDeductible
Inpatient doctor and surgical services : InNetwork:NoChargeAfterDeductible
: OutofNetwork:50%Coinsuranceafterdeductible
Inpatient hospital services (like a hospital stay) : InNetwork:NoChargeAfterDeductible
: OutofNetwork:$1500CopayperStaybefore
deductible/50%Coinsuranceafterdeductible
Typical cost for a healthy pregnancy and normal
delivery.
$7,400
Typical yearly cost for managing type 2 diabetes
for one person.
$5,380
Routine dental care : InNetwork:BenefitNotCovered
Basic dental care : InNetwork:BenefitNotCovered
Major dental care : InNetwork:BenefitNotCovered
Orthodontia :InNetwork:BenefitNotCovered
Check-up : InNetwork:BenefitNotCovered
Major dental care : InNetwork:BenefitNotCovered
Basic dental care : InNetwork:BenefitNotCovered
Medically necessary orthodontia Orthodontic
treatment may require pre-approval and must
meet the plan's 'medical necessity' criteria.
: InNetwork:BenefitNotCovered
ProviderdirectoryURL :  View
NationalProvide rNetwork : Yes
Needreferra ltoseeaspecial ist : No
Hospitalservices
: CostCoverageExamples
Adultdentalcoverage
Childdentalcoverage
Medicalmanagementprograms
Asthma : : Available
Heartdisease : : Available
: