| DEATH AND DISMEMBERMENT BENEFITS |
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| For employees (insured benefits): |
| Life Insurance Benefit Amount | $15,000 |
| Accidental Death & Dismembership Insurance (full amount) | $10,000 |
|
| For dependents of employees (self-funded benefits): |
| Death Benefit for spouse and children age 14 days but less than 19 years | $1,000 |
| Accidental Death & Dismemberment Benefit (full amount) | $2,000 |
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WEEKLY DISABILITY BENEFIT
(For Employees Only) |
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| Amount of Weekly Benefit | $250 |
| Maximum period that benefits are payable | Up to 26 weeks |
| When disability benefits start | 8th day after first day of treatment |
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| COMPREHENSIVE BENEFIT |
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Benefit Reductions and Exclusions
Certain benefit reductions and exclusions apply when the precertification is not obtained. All benefits and provisions are per person unless specifically stated otherwise. |
| Calendar year deductible: | |
| Per person | $500 |
| Per family (can be satisfied by two or more family members) | $1,000 |
| Out-of-network hospital penalty | $250 |
| The out-of-network hospital penalty applies to each non-emergency hospital confinement and each occurrence of non-emergency outpatient treatment in an out-of-network hospital (some exceptions apply). Any such deductibles are in addition to the calendar year deductibles. |
| Out-of-pocket limit: |
| Per person | $2,500 |
| Per family (can be satisfied by two or more family members) | $5,000 |
| Only in-network covered medical expenses apply toward your out-of-pocket limit; prescription drug expenses are subject to a separate out-of-pocket limit. The calendar year deductible also applies toward the out-of-pocket limit. |
Plan co-pay/payment percentages payable per person for covered medical expenses incurred during a calendar year, until out-of-pocket limit is met.
Exceptions may apply. Those exceptions are noted in the “Special Benefits and Limitations” section below. | 80% |
|
Applied Behavior Analysis (ABA) Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care | 50 Visits per calendar year |
Acupuncture
Must be pre-certified by Med-Care. Calendar year deductible does not apply. | 12 Visits per calendar year |
Aqua Therapy
(subject to the medical necessity criteria)
Must be pre-certified by Med-Care | No limit per calendar year |
Chair Lift
Lifetime maximum benefit for purchase and installation of a chair lift that meets the re-quirements in No. 16-i
Must be pre-certified by Med-Care | $10,000 |
Chiropractic Care
Calendar year maximum benefit per person (includes adjustments and manipulations). Physical therapy, acupuncture and massage therapy have separate limitations.
Must be pre-certified by Med-Care. Calendar year deductible does not apply. | $2,500 |
Hearing aids:
Maximum benefit payable per person | $3,000 in a two-calendar year period |
Plan co-payment percentage
Calendar year deductible does not apply | 50% |
Massage Therapy
subject to the medical necessity criteria explained below
Must be pre-certified by Med-Care. Calendar year deductible does not apply. | 12 visits per calendar year |
Nutrition Counseling
subject to the medical necessity criteria explained in section below
Must be pre-certified by Med-Care. Calendar year deductible does not apply. | 12 visits per calendar year |
Occupational Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care | 50 visits |
| Out-of-network surgical facility charges | Excluded |
Physical Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care | 50 visits |
Podiatry
Calendar year maximum benefit per person for all non-surgical podiatry fees
(professional fees only) Calendar year deductible does not apply | $750 |
Preventive care
When provided by in-network providers
| 100% deductible does not apply |
| When provided by out-of-network providers | 80% of the allowable charge after deductible |
| Second or third surgical opinions recommended by Med-Care | 100% |
Speech Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care | 50 visits |
TMJ
Lifetime maximum benefit for non-surgical treatment (professional fees only)
Must be pre-certified by Med-Care. Calendar year deductible does not apply | $2,000 |
Travel Abroad
Maximum amount paid per participant per occurrence for medical expenses incurred while traveling abroad.
Calendar year deductible does not apply | $250 |
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| PRESCRIPTION DRUGS |
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| Your co-pays under the Sav-Rx drug card program for up to a 30-day supply of a covered prescription drug obtained from a participating pharmacy, and under the Sav-Rx mail-order and Walgreens walk-in programs, are based on a percentage of the negotiated price for the drug. |
| | Your Co-Pay |
| Generic Drugs | 10% |
| Formulary brand name drugs | 20% |
| Non-formulary brands | 30% |
| Lifestyle drugs | 40% |
| Proton pump inhibitors (such as Nexium, Prevacid and Prilosec) | Excluded* |
| Non-sedating antihistamines (such as prescription Claritin and Allegra) | Excluded* |
| There is a $5 minimum and $200 maximum on each co-pay. | |
| If the total amount paid in co-pay percentages reach the following amounts during a calendar year, the Plan will pay 100% for the person’s (or family’s) covered prescription drug expenses during the remainder of that calendar year: |
| | Rx Out-of-Pocket Limit |
| Per person | $3,000 |
| Per family | $5,000 |
* PPIs and NSAHs are only covered if Med-Care pre-authorizes your use of a prescription version.
|
Generic/Brand Differential (Card, Mail and Walk-In) – If you chose a brand name drug when a generic equiva-lent is available, you will be responsible for the difference in cost between the brand and the generic equivalent, in addition to your percentage co-pay. The cost difference that you pay does not apply to the Rx out-of-pocket limit.
Prior Authorization and Clinical Review – Specialty drugs and other high-cost medications may require prior authorization by clinical personnel at Sav-Rx and/or Med-Care Management. The Plan has the right to exclude a high-cost drug if there are less expensive but clinically appropriate alternatives available.
Out-of-network prescriptions drugs are not covered. |
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| VISION BENEFIT |
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Plan payment percentage:
Employees and spouses | 80% |
| Children (under age 26) | 100% |
| Maximum benefit payable per calendar year for all covered vision services and supplies | $500 |
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| DENTAL BENEFIT |
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| Dental HMO Plan (BlueCare Dental HMO) | |
| Deductible | None |
| Diagnostic and preventive services (check-ups and cleanings) and x-rays | Provided at no charge |
| All other covered dental procedures | Provided in full after patient co-payment shown in the DHMO Plan brochure |
Calendar year maximum benefit
When you enroll in the BlueCare Dental HMO, you will be sent a certificate of coverage with the schedule of dental services and patient co-payments | No maximum |
| Dental PPO Plan (Dental Network of America, a BCBSIL Subsidiary) | |
| Calendar year deductible per person (does not apply to diagnostic and preventive care) | $50 |
| Plan co-pay percentages of R&C allowances: | |
| In-Network | |
| Diagnostic and preventive | 100% |
| Restorative (minor and major) | 90% |
| Out-of-Network | |
| Diagnostic and preventive | 100% |
| Restorative (minor and major) | 80% |
Calendar year maximum benefit payable per person
Calendar year maximum does not apply to diagnostic and preventive services received by persons under age 19 | $1,500 |
| Lifetime maximum benefit payable per person for orthodontia | $2,000 |
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