Medical Plans

Your medical benefit: to most, it’s the most important benefit we have available, but many of us don’t use our plan to the fullest. Medical benefits are not just for when you are sick... For example, if you use preventive benefits when you are well, you might actually be able to avoid getting sick!

Select A Plan

Select A Benefit Plan

BCBSIL HSA Plan BCBSIL HMO Plan BCBSIL Blue Choice Select PPO BCBSIL HMO Blue Advantage Plan

This is a brief description of benefits. Please refer to the Plan Documents for complete policy provisions, limitations, and exclusions. If a conflict arises between this summary and the Plan Documents, the Plan Documents will prevail.

Deductible

In-network:
Individual: $2,500
Family: $5,000

Out-of-network:
Individual: $2,500
Family: $5,000

Deductible

In-network:
Individual: $5,000
Family: $10,000

Out-of-network:
Individual: $10,000
Family: $20,000

Deductible

In-network:
Individual: No deductible
Family: No deductible

Out-of-network:
Not covered

Deductible

In-network:
Individual: $2,500
Family: $5,000

Out-of-network:
Individual: $2,500
Family: $5,000

Deductible

In-network:
Individual: No deductible
Family: No deductible

Out-of-network:
Not covered

Coinsurance

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Coinsurance

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Coinsurance

In-network:
You pay 0%
Plan pays 100%

Out-of-network:
Not covered

Coinsurance

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Coinsurance

In-network:
You pay 0%
Plan pays 100%

Out-of-network:
Not covered

Out-of-Pocket Maximum

In-network:
Individual: $6,500
Family: $13,000

Out-of-network:
Individual: $8,500
Family: $17,000

Out-of-Pocket Maximum

In-network:
Individual: $7,000
Family: $14,000

Out-of-network:
Individual: $14,000
Family: $28,000

Out-of-Pocket Maximum

In-network:
Individual: $4,000
Family: $8,000

Out-of-network:
Not covered

Out-of-Pocket Maximum

In-network:
Individual: $6,500
Family: $13,000

Out-of-network:
Individual: $8,500
Family: $17,000

Out-of-Pocket Maximum

In-network:
Individual: $4,000
Family: $8,000

Out-of-network:
Not covered

Virtual Visit

In-network:
You pay $25

Out-of-network:
Not Covered

Virtual Visit

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
Not Covered

Virtual Visit

In-network:
Not covered

Out-of-network:
Not covered

Virtual Visit

In-network:
You pay $25

Out-of-network:
Not Covered

Virtual Visit

In-network:
Not covered

Out-of-network:
Not covered

Doctor’s Office Visit

In-network:
You pay $30

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Doctor’s Office Visit

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Doctor’s Office Visit

In-network:
You pay $30 copay then plan pays 100%

Out-of-network:
Not covered

Doctor's Office Visit

In-network:
You pay $30

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Doctor's Office Visit

In-network:
You pay $30 copay then plan pays 100%

Out-of-network:
Not covered

Specialist Office Visit

In-network:
You pay $60

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Specialist Office Visit

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Specialist Office Visit

In-network:
You pay $60 copay then plan pays 100%

Out-of-network:
Not covered

Specialist Office Visit

In-network:
You pay $60

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Specialist Office Visit

In-network:
You pay $60 copay then plan pays 100%

Out-of-network:
Not covered

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-Network:
You pay 40% (after deductible)
Plan pays 60%

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-Network:
You pay 40% (after deductible)
Plan pays 60%

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
Not covered

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-Network:
You pay 40% (after deductible)
Plan pays 60%

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
Not covered

Emergency Room

In-network:
You pay $250 copay

Out-of-network:
You pay $250 copay

Emergency Room

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Emergency Room

In-network:
You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)

Out-of-network:
You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)

Emergency Room

In-network:
You pay $250 copay

Out-of-network:
You pay $250 copay

Emergency Room

In-network:
You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)

Out-of-network:
You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)

Urgent Care

In-network:
Your cost will depend on how the provider is contracted and how the claim is billed (Emergency: $250, Urgent Care: $75, Primary Care: $30)

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Urgent Care

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Urgent Care

In-network:
you pay a $30 copay (Must be affiliated with medical group or Referral required)

Out-of-network:
Not covered

Urgent Care

In-network:
Your cost will depend on how the provider is contracted and how the claim is billed (Emergency: $250, Urgent Care: $75, Primary Care: $30)

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Urgent Care

In-network:
you pay a $30 copay (Must be affiliated with medical group or Referral required)

Out-of-network:
Not covered

Inpatient Hospitalization

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay a $400 copay, then 40% (after deductible)
Plan pays 60%

Inpatient Hospitalization

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay a $400 copay, then 40% (after deductible)
Plan pays 60%

Inpatient Hospitalization

In-network:
you pay $750 copay/day ($3,000/Calendar Year)

Out-of-network:
Not covered

Inpatient Hospitalization

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay a $400 copay, then 40% (after deductible)
Plan pays 60%

Hospitalization

In-network:
you pay $750 copay/day ($3,000/Calendar Year)

Out-of-network:
Not covered

Outpatient Surgery

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Outpatient Surgery

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Outpatient Surgery

In-network:
you pay $500 copay then plan pays 100%

Out-of-network:
Not covered

Outpatient Surgery

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Outpatient Surgery

In-network:
you pay $500 copay then plan pays 100%

Out-of-network:
Not covered

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

Yes (exceptions may be made in an emergency)

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

Yes (exceptions may be made in an emergency)

Do you need a referral to a specialist?

Yes

Do you need a referral to see a specialist?

Do you need a referral to a specialist?

Yes

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Yes

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Can I use a Health Care Flexible Spending Account (FSA)?

Yes

Can I use a Health Care Flexible Spending Account (FSA)?

Yes

Can I use a Health Care Flexible Spending Account (FSA)?

Yes

Can I use a Health Care Flexible Spending Account (FSA)?

Yes

Prescription Drug

Retail (Up to 31-day supply)
In- or out-of-network*:
Generic: $15 copay
Brand** (Formulary): 30%
($50 maximum copay)
Brand** (Non-Formulary): 50%
($75 maximum copay)
Select oral contraceptives: $0

Mail Order (Up to 90-day supply)
In-network only:
Generic: $30 copay
Brand** (Formulary): 30%
($100 maximum copay)
Brand** (Non-Formulary): 50%
($150 maximum copay)
Preferred Specialty***: $75 copay
Non-Preferred Specialty***: $100 copay
Select oral contraceptives: $0

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

**If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent

***Specialty drugs are limited to 30 day supply

Prescription Drug

Retail (Up to 31-day supply)
In- or out-of-network*:
Generic: $15 copay
Brand (Formulary): 30%
($50 maximum copay)
Brand (Non-Formulary): 50%
($75 maximum copay)
Select oral contraceptives: $0

Mail Order (Up to 90-day supply)
In-network only:
Generic: $30 copay
Brand (Formulary): 30%
($100 maximum copay)
Brand (Non-Formulary): 50%
($150 maximum copay)
Preferred Specialty**: Applicable retail copays apply
Non-Preferred Specialty**: Applicable retail copays apply
Select oral contraceptives: $0

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

**Specialty drugs are limited to 30 day supply

Prescription Drug

Retail (Up to 31-day supply)
In-network:
Generic: $15 copay
Brand** (Formulary): 30%
($50 maximum copay)
Brand** (Non-Formulary): 50%
($75 maximum copay)
Select oral contraceptives: $0

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

***Specialty drugs are limited to 30 day supply

Prescription Drug

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

***Specialty drugs are limited to 30 day supply

Prescription Drug

Retail (Up to 31-day supply)
In-network:
Generic: $15 copay
Brand** (Formulary): 30%
($50 maximum copay)
Brand** (Non-Formulary): 50%
($75 maximum copay)
Select oral contraceptives: $0

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

***Specialty drugs are limited to 30 day supply

Contributions

Annual base salary $67,000 or Less
Employee (EE) only: $244.00
EE + spouse/domestic partner/civil union partner: $774.44
EE + child(ren): $518.06
Family: $878.75

Annual base salary $67,001 - $95,000
EE only: $266.99
EE + spouse/domestic partner/civil union partner: $889.37
EE + child(ren): $610.00
Family: $954.78

Annual base salary $95,001 +
EE only: $289.97
EE + spouse/domestic partner/civil union partner: $1,000.76
EE + child(ren): $703.71
Family: $1,066.17

Contributions

Annual base salary $67,000 or Less
EE only: $195.11
EE + spouse/domestic partner/civil union partner: $619.41
EE + child(ren): $415.01
Family: $703.01

Annual base salary $67,001 - $95,000
EE only: $213.69
EE + spouse/domestic partner/civil union partner: $710.77
EE + child(ren): $487.78
Family: $763.41

Annual base salary $95,001 +
EE only: $232.28
EE + spouse/domestic partner/civil union partner: $800.58
EE + child(ren): $562.11
Family: $853.22

Contributions

Annual base salary $67,000 or Less

Employee only: $171.55
Employee + spouse/domestic partner/civil union partner: $544.49
Employee + child(ren): $364.24
Employee + family: $617.84

Annual base salary $67,001 - $95,000

Employee only: $187.72
Employee + spouse/domestic partner/civil union partner: $625.30
Employee + child(ren): $428.88
Employee + family: $671.29

Annual base salary $95,001 +

Employee Only: $203.87
Employee + spouse/domestic partner/civil union partner: $703.62
Employee + Child(ren): $494.77
Employee + Family: $749.61

Contributions

Annual base salary $67,000 or Less
EE only: $202.83
EE + spouse/domestic partner/civil union partner: $643.75
EE + child(ren): $430.64
Family: $730.47

Annual base salary $67,001 - $95,000
EE only: $221.94
EE + spouse/domestic partner/civil union partner: $739.29
EE + child(ren): $507.06
Family: $793.66

Annual base salary $95,001 +
EE only: $241.04
EE + spouse/domestic partner/civil union partner: $831.89
EE + child(ren): $584.97
Family: $886.26

Contributions

Annual base salary $67,000 or Less

Employee only: $161.26
Employee + spouse/domestic partner/civil union partner: $511.82
Employee + child(ren): $342.39
Employee + family: $580.77

Annual base salary $67,001 - $95,000

Employee only: $176.46
Employee + spouse/domestic partner/civil union partner: $587.78
Employee + child(ren): $403.15
Employee + family: $631.01

Annual base salary $95,001 +

Employee Only: $191.64
Employee + spouse/domestic partner/civil union partner: $661.40
Employee + Child(ren): $465.08
Employee + Family: $704.63

Plan Documents Resources Comparison

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits. Copays do not apply.	In-network: Individual: $2,500 Family: $5,000	Out-of-network: Individual: $2,500 Family: $5,000
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Includes deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $6,500 Family: $13,000	Out-of-network: Individual: $8,500 Family: $17,000
Virtual Visit	In-network: You pay $25	Out-of-network: Not Covered
Doctor’s Office Visit	In-network: You pay $30	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay $60	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-Network: You pay 40% (after deductible) Plan pays 60%
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay $250 copay	Out-of-network: You pay $250 copay
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: Your cost will depend on how the provider is contracted and how the claim is billed (Emergency: $250, Urgent Care: $75, Primary Care: $30)	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Inpatient Hospitalization	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay a $400 copay, then 40% (after deductible) Plan pays 60%
Outpatient Surgery	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
	No (but your costs will be lower when you do)
Do you need a referral to a specialist?	No
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	No
Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	Yes
Prescription Drug	Retail (Up to 31-day supply) In- or out-of-network:* Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty*: $75 copay Non-Preferred Specialty: $100 copay Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent *Specialty drugs are limited to 30 day supply
Contributions Contributions Monthly medical pre-tax payroll deductions	Annual base salary $67,000 or Less Employee (EE) only: $244.00 EE + spouse/domestic partner/civil union partner: $774.44 EE + child(ren): $518.06 Family: $878.75 Annual base salary $67,001 - $95,000 EE only: $266.99 EE + spouse/domestic partner/civil union partner: $889.37 EE + child(ren): $610.00 Family: $954.78 Annual base salary $95,001 + EE only: $289.97 EE + spouse/domestic partner/civil union partner: $1,000.76 EE + child(ren): $703.71 Family: $1,066.17

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits. Copays do not apply.	In-network: Individual: $2,500 Family: $5,000	Out-of-network: Individual: $2,500 Family: $5,000
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Includes deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $6,500 Family: $13,000	Out-of-network: Individual: $8,500 Family: $17,000
Virtual Visit	In-network: You pay $25	Out-of-network: Not Covered
Doctor’s Office Visit	In-network: You pay $30	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay $60	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-Network: You pay 40% (after deductible) Plan pays 60%
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay $250 copay	Out-of-network: You pay $250 copay
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: Your cost will depend on how the provider is contracted and how the claim is billed (Emergency: $250, Urgent Care: $75, Primary Care: $30)	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Inpatient Hospitalization	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay a $400 copay, then 40% (after deductible) Plan pays 60%
Outpatient Surgery	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Are you required to use network providers?	No (but your costs will be lower when you do)
Do you need a referral to a specialist?	No
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	No
Can I use a Health Care Flexible Spending Account (FSA)? Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	Yes
Prescription Drug	Retail (Up to 31-day supply) In- or out-of-network:* Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty*: $75 copay Non-Preferred Specialty: $100 copay Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent *Specialty drugs are limited to 30 day supply
Contributions Contributions Monthly medical pre-tax payroll deductions	Annual base salary $67,000 or Less Employee (EE) only: $244.00 EE + spouse/domestic partner/civil union partner: $774.44 EE + child(ren): $518.06 Family: $878.75 Annual base salary $67,001 - $95,000 EE only: $266.99 EE + spouse/domestic partner/civil union partner: $889.37 EE + child(ren): $610.00 Family: $954.78 Annual base salary $95,001 + EE only: $289.97 EE + spouse/domestic partner/civil union partner: $1,000.76 EE + child(ren): $703.71 Family: $1,066.17

Plan Documents Resources Comparison

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits.	In-network: Individual: $5,000 Family: $10,000	Out-of-network: Individual: $10,000 Family: $20,000
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Includes deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $7,000 Family: $14,000	Out-of-network: Individual: $14,000 Family: $28,000
Virtual Visit	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: Not Covered
Doctor’s Office Visit	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-Network: You pay 40% (after deductible) Plan pays 60%
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 20% (after deductible) Plan pays 80%
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Inpatient Hospitalization	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay a $400 copay, then 40% (after deductible) Plan pays 60%
Outpatient Surgery	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
	No (but your costs will be lower when you do)
Do you need a referral to a specialist?	No
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	Yes
Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	No
Prescription Drug	Retail (Up to 31-day supply) In- or out-of-network:* Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty: Applicable retail copays apply Non-Preferred Specialty: Applicable retail copays apply Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. *Specialty drugs are limited to 30 day supply
Contributions Contributions Monthly medical pre-tax payroll deductions	Annual base salary $67,000 or Less EE only: $195.11 EE + spouse/domestic partner/civil union partner: $619.41 EE + child(ren): $415.01 Family: $703.01 Annual base salary $67,001 - $95,000 EE only: $213.69 EE + spouse/domestic partner/civil union partner: $710.77 EE + child(ren): $487.78 Family: $763.41 Annual base salary $95,001 + EE only: $232.28 EE + spouse/domestic partner/civil union partner: $800.58 EE + child(ren): $562.11 Family: $853.22

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits.	In-network: Individual: $5,000 Family: $10,000	Out-of-network: Individual: $10,000 Family: $20,000
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Includes deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $7,000 Family: $14,000	Out-of-network: Individual: $14,000 Family: $28,000
Virtual Visit	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: Not Covered
Doctor’s Office Visit	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-Network: You pay 40% (after deductible) Plan pays 60%
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 20% (after deductible) Plan pays 80%
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Inpatient Hospitalization	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay a $400 copay, then 40% (after deductible) Plan pays 60%
Outpatient Surgery	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Are you required to use network providers?	No (but your costs will be lower when you do)
Do you need a referral to a specialist?	No
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	Yes
Can I use a Health Care Flexible Spending Account (FSA)? Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	No
Prescription Drug	Retail (Up to 31-day supply) In- or out-of-network:* Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty: Applicable retail copays apply Non-Preferred Specialty: Applicable retail copays apply Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. *Specialty drugs are limited to 30 day supply
Contributions Contributions Monthly medical pre-tax payroll deductions	Annual base salary $67,000 or Less EE only: $195.11 EE + spouse/domestic partner/civil union partner: $619.41 EE + child(ren): $415.01 Family: $703.01 Annual base salary $67,001 - $95,000 EE only: $213.69 EE + spouse/domestic partner/civil union partner: $710.77 EE + child(ren): $487.78 Family: $763.41 Annual base salary $95,001 + EE only: $232.28 EE + spouse/domestic partner/civil union partner: $800.58 EE + child(ren): $562.11 Family: $853.22

Plan Documents Resources Comparison

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits. Copays do not apply.	In-network: Individual: No deductible Family: No deductible	Out-of-network: Not covered
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 0% Plan pays 100%	Out-of-network: Not covered
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Includes deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $4,000 Family: $8,000	Out-of-network: Not covered
Virtual Visit	In-network: Not covered	Out-of-network: Not covered
Doctor’s Office Visit	In-network: You pay $30 copay then plan pays 100%	Out-of-network: Not covered
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay $60 copay then plan pays 100%	Out-of-network: Not covered
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-network: Not covered
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)	Out-of-network:
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: you pay a $30 copay (Must be affiliated with medical group or Referral required)	Out-of-network: Not covered
Inpatient Hospitalization	In-network: you pay $750 copay/day ($3,000/Calendar Year)	Out-of-network: Not covered
Outpatient Surgery	In-network: you pay $500 copay then plan pays 100%	Out-of-network: Not covered
	Yes (exceptions may be made in an emergency)
Do you need a referral to a specialist?	Yes
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	No
Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	Yes
Prescription Drug	Retail (Up to 31-day supply) In-network: Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty*: $75 copay Non-Preferred Specialty: $100 copay Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent *Specialty drugs are limited to 30 day supply
Contributions Contributions Monthly medical pre-tax payroll deductions	Annual base salary $67,000 or Less Employee only: $171.55 Employee + spouse/domestic partner/civil union partner: $544.49 Employee + child(ren): $364.24 Employee + family: $617.84 Annual base salary $67,001 - $95,000 Employee only: $187.72 Employee + spouse/domestic partner/civil union partner: $625.30 Employee + child(ren): $428.88 Employee + family: $671.29 Annual base salary $95,001 + Employee Only: $203.87 Employee + spouse/domestic partner/civil union partner: $703.62 Employee + Child(ren): $494.77 Employee + Family: $749.61

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits. Copays do not apply.	In-network: Individual: No deductible Family: No deductible	Out-of-network: Not covered
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 0% Plan pays 100%	Out-of-network: Not covered
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Includes deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $4,000 Family: $8,000	Out-of-network: Not covered
Virtual Visit	In-network: Not covered	Out-of-network: Not covered
Doctor’s Office Visit	In-network: You pay $30 copay then plan pays 100%	Out-of-network: Not covered
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay $60 copay then plan pays 100%	Out-of-network: Not covered
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-network: Not covered
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)	Out-of-network: You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: you pay a $30 copay (Must be affiliated with medical group or Referral required)	Out-of-network: Not covered
Inpatient Hospitalization	In-network: you pay $750 copay/day ($3,000/Calendar Year)	Out-of-network: Not covered
Outpatient Surgery	In-network: you pay $500 copay then plan pays 100%	Out-of-network: Not covered
Are you required to use network providers?	Yes (exceptions may be made in an emergency)
Do you need a referral to a specialist?	Yes
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	No
Can I use a Health Care Flexible Spending Account (FSA)? Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	Yes
Prescription Drug	Retail (Up to 31-day supply) In-network: Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty*: $75 copay Non-Preferred Specialty: $100 copay Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent *Specialty drugs are limited to 30 day supply
Contributions Contributions Monthly medical pre-tax payroll deductions	Annual base salary $67,000 or Less Employee only: $171.55 Employee + spouse/domestic partner/civil union partner: $544.49 Employee + child(ren): $364.24 Employee + family: $617.84 Annual base salary $67,001 - $95,000 Employee only: $187.72 Employee + spouse/domestic partner/civil union partner: $625.30 Employee + child(ren): $428.88 Employee + family: $671.29 Annual base salary $95,001 + Employee Only: $203.87 Employee + spouse/domestic partner/civil union partner: $703.62 Employee + Child(ren): $494.77 Employee + Family: $749.61

Plan Documents Resources Comparison

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits. Copays do not apply.	In-network: Individual: $2,500 Family: $5,000	Out-of-network: Individual: $2,500 Family: $5,000
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Incldues deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $6,500 Family: $13,000	Out-of-network: Individual: $8,500 Family: $17,000
Virtual Visit	In-network: You pay $25	Out-of-network: Not Covered
Doctor's Office Visit	In-network: You pay $30	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay $60	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-Network: You pay 40% (after deductible) Plan pays 60%
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay $250 copay	Out-of-network: You pay $250 copay
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: Your cost will depend on how the provider is contracted and how the claim is billed (Emergency: $250, Urgent Care: $75, Primary Care: $30)	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Inpatient Hospitalization	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay a $400 copay, then 40% (after deductible) Plan pays 60%
Outpatient Surgery	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
	No (but your costs will be lower when you do)
	No
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	No
Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	Yes
Prescription Drug	Retail (Up to 31-day supply) In- or out-of-network:* Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty*: $75 copay Non-Preferred Specialty: $100 copay Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent *Specialty drugs are limited to 30 day supply
Contributions	Annual base salary $67,000 or Less EE only: $202.83 EE + spouse/domestic partner/civil union partner: $643.75 EE + child(ren): $430.64 Family: $730.47 Annual base salary $67,001 - $95,000 EE only: $221.94 EE + spouse/domestic partner/civil union partner: $739.29 EE + child(ren): $507.06 Family: $793.66 Annual base salary $95,001 + EE only: $241.04 EE + spouse/domestic partner/civil union partner: $831.89 EE + child(ren): $584.97 Family: $886.26

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits. Copays do not apply.	In-network: Individual: $2,500 Family: $5,000	Out-of-network: Individual: $2,500 Family: $5,000
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Incldues deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $6,500 Family: $13,000	Out-of-network: Individual: $8,500 Family: $17,000
Virtual Visit	In-network: You pay $25	Out-of-network: Not Covered
Doctor's Office Visit	In-network: You pay $30	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay $60	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-Network: You pay 40% (after deductible) Plan pays 60%
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay $250 copay	Out-of-network: You pay $250 copay
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: Your cost will depend on how the provider is contracted and how the claim is billed (Emergency: $250, Urgent Care: $75, Primary Care: $30)	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Inpatient Hospitalization	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay a $400 copay, then 40% (after deductible) Plan pays 60%
Outpatient Surgery	In-network: You pay 20% (after deductible) Plan pays 80%	Out-of-network: You pay 40% (after deductible) Plan pays 60%
Are you required to use network providers?	No (but your costs will be lower when you do)
Do you need a referral to see a specialist?	No
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	No
Can I use a Health Care Flexible Spending Account (FSA)? Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	Yes
Prescription Drug	Retail (Up to 31-day supply) In- or out-of-network:* Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty*: $75 copay Non-Preferred Specialty: $100 copay Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent *Specialty drugs are limited to 30 day supply
Contributions	Annual base salary $67,000 or Less EE only: $202.83 EE + spouse/domestic partner/civil union partner: $643.75 EE + child(ren): $430.64 Family: $730.47 Annual base salary $67,001 - $95,000 EE only: $221.94 EE + spouse/domestic partner/civil union partner: $739.29 EE + child(ren): $507.06 Family: $793.66 Annual base salary $95,001 + EE only: $241.04 EE + spouse/domestic partner/civil union partner: $831.89 EE + child(ren): $584.97 Family: $886.26

Plan Documents Resources Comparison

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits. Copays do not apply.	In-network: Individual: No deductible Family: No deductible	Out-of-network: Not covered
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 0% Plan pays 100%	Out-of-network: Not covered
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Includes deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $4,000 Family: $8,000	Out-of-network: Not covered
Virtual Visit	In-network: Not covered	Out-of-network: Not covered
Doctor's Office Visit	In-network: You pay $30 copay then plan pays 100%	Out-of-network: Not covered
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay $60 copay then plan pays 100%	Out-of-network: Not covered
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-network: Not covered
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)	Out-of-network: You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: you pay a $30 copay (Must be affiliated with medical group or Referral required)	Out-of-network: Not covered
Hospitalization	In-network: you pay $750 copay/day ($3,000/Calendar Year)	Out-of-network: Not covered
Outpatient Surgery	In-network: you pay $500 copay then plan pays 100%	Out-of-network: Not covered
	Yes (exceptions may be made in an emergency)
Do you need a referral to a specialist?	Yes
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	No
Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	Yes
Prescription Drug	Retail (Up to 31-day supply) In-network: Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty*: $75 copay Non-Preferred Specialty: $100 copay Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent *Specialty drugs are limited to 30 day supply
Contributions Contributions Monthly medical pre-tax payroll deductions	Annual base salary $67,000 or Less Employee only: $161.26 Employee + spouse/domestic partner/civil union partner: $511.82 Employee + child(ren): $342.39 Employee + family: $580.77 Annual base salary $67,001 - $95,000 Employee only: $176.46 Employee + spouse/domestic partner/civil union partner: $587.78 Employee + child(ren): $403.15 Employee + family: $631.01 Annual base salary $95,001 + Employee Only: $191.64 Employee + spouse/domestic partner/civil union partner: $661.40 Employee + Child(ren): $465.08 Employee + Family: $704.63

Deductible Deductible The amount of covered expenses you must pay before the Plan starts paying benefits. Copays do not apply.	In-network: Individual: No deductible Family: No deductible	Out-of-network: Not covered
Coinsurance Coinsurance Cost-sharing between you and the company. This is applied after you meet your deductible.	In-network: You pay 0% Plan pays 100%	Out-of-network: Not covered
Out-of-Pocket Maximum Out-of-Pocket Maximum The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply. Includes deductible, coinsurance for essential health benefits and all copays INCLUDING pharmacy.	In-network: Individual: $4,000 Family: $8,000	Out-of-network: Not covered
Virtual Visit	In-network: Not covered	Out-of-network: Not covered
Doctor's Office Visit	In-network: You pay $30 copay then plan pays 100%	Out-of-network: Not covered
Specialist Office Visit Specialist Office Visit Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).	In-network: You pay $60 copay then plan pays 100%	Out-of-network: Not covered
Preventive/Well Child Care Preventive/Well Child Care Care focused on prevention or early detection of health conditions. Includes routine physical exam, child immunizations, and routine diagnostic tests.	In-network: You pay $0 Plan pays 100%	Out-of-network: Not covered
Emergency Room Emergency Room Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.	In-network: You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)	Out-of-network: You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)
Urgent Care Urgent Care Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.	In-network: you pay a $30 copay (Must be affiliated with medical group or Referral required)	Out-of-network: Not covered
Hospitalization	In-network: you pay $750 copay/day ($3,000/Calendar Year)	Out-of-network: Not covered
Outpatient Surgery	In-network: you pay $500 copay then plan pays 100%	Out-of-network: Not covered
Are you required to use network providers?	Yes (exceptions may be made in an emergency)
Do you need a referral to a specialist?	Yes
Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)? A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.	No
Can I use a Health Care Flexible Spending Account (FSA)? Can I use a Health Care Flexible Spending Account (FSA)? An account you contribute to before taxes, then use the money for qualified health-related expenses.	Yes
Prescription Drug	Retail (Up to 31-day supply) In-network: Generic: $15 copay Brand (Formulary): 30% ($50 maximum copay) Brand (Non-Formulary): 50% ($75 maximum copay) Select oral contraceptives: $0 Mail Order (Up to 90-day supply) In-network only: Generic: $30 copay Brand (Formulary): 30% ($100 maximum copay) Brand (Non-Formulary): 50% ($150 maximum copay) Preferred Specialty*: $75 copay Non-Preferred Specialty: $100 copay Select oral contraceptives: $0 Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay. If an insured selected a brand name drug when there is a generic equivalent available, the member will pay the applicable copay plus the cost difference between the selected drug and the generic equivalent *Specialty drugs are limited to 30 day supply
Contributions Contributions Monthly medical pre-tax payroll deductions	Annual base salary $67,000 or Less Employee only: $161.26 Employee + spouse/domestic partner/civil union partner: $511.82 Employee + child(ren): $342.39 Employee + family: $580.77 Annual base salary $67,001 - $95,000 Employee only: $176.46 Employee + spouse/domestic partner/civil union partner: $587.78 Employee + child(ren): $403.15 Employee + family: $631.01 Annual base salary $95,001 + Employee Only: $191.64 Employee + spouse/domestic partner/civil union partner: $661.40 Employee + Child(ren): $465.08 Employee + Family: $704.63

BCBSIL PPO Plan

BCBSIL HSA Plan

BCBSIL HMO Plan

BCBSIL Blue Choice Select PPO

BCBSIL HMO Blue Advantage Plan

Deductible

In-network:
Individual: $2,500
Family: $5,000

Out-of-network:
Individual: $2,500
Family: $5,000

Deductible

In-network:
Individual: $5,000
Family: $10,000

Out-of-network:
Individual: $10,000
Family: $20,000

Deductible

In-network:
Individual: No deductible
Family: No deductible

Out-of-network:
Not covered

Deductible

In-network:
Individual: $2,500
Family: $5,000

Out-of-network:
Individual: $2,500
Family: $5,000

Deductible

In-network:
Individual: No deductible
Family: No deductible

Out-of-network:
Not covered

Coinsurance

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Coinsurance

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Coinsurance

In-network:
You pay 0%
Plan pays 100%

Out-of-network:
Not covered

Coinsurance

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Coinsurance

In-network:
You pay 0%
Plan pays 100%

Out-of-network:
Not covered

Out-of-Pocket Maximum

In-network:
Individual: $6,500
Family: $13,000

Out-of-network:
Individual: $8,500
Family: $17,000

Out-of-Pocket Maximum

In-network:
Individual: $7,000
Family: $14,000

Out-of-network:
Individual: $14,000
Family: $28,000

Out-of-Pocket Maximum

In-network:
Individual: $4,000
Family: $8,000

Out-of-network:
Not covered

Out-of-Pocket Maximum

In-network:
Individual: $6,500
Family: $13,000

Out-of-network:
Individual: $8,500
Family: $17,000

Out-of-Pocket Maximum

In-network:
Individual: $4,000
Family: $8,000

Out-of-network:
Not covered

Virtual Visit

In-network:
You pay $25

Out-of-network:
Not Covered

Virtual Visit

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
Not Covered

Virtual Visit

In-network:
Not covered

Out-of-network:
Not covered

Virtual Visit

In-network:
You pay $25

Out-of-network:
Not Covered

Virtual Visit

In-network:
Not covered

Out-of-network:
Not covered

Doctor’s Office Visit

In-network:
You pay $30

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Doctor’s Office Visit

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Doctor’s Office Visit

In-network:
You pay $30 copay then plan pays 100%

Out-of-network:
Not covered

Doctor's Office Visit

In-network:
You pay $30

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Doctor's Office Visit

In-network:
You pay $30 copay then plan pays 100%

Out-of-network:
Not covered

Specialist Office Visit

In-network:
You pay $60

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Specialist Office Visit

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Specialist Office Visit

In-network:
You pay $60 copay then plan pays 100%

Out-of-network:
Not covered

Specialist Office Visit

In-network:
You pay $60

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Specialist Office Visit

In-network:
You pay $60 copay then plan pays 100%

Out-of-network:
Not covered

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-Network:
You pay 40% (after deductible)
Plan pays 60%

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-Network:
You pay 40% (after deductible)
Plan pays 60%

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
Not covered

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-Network:
You pay 40% (after deductible)
Plan pays 60%

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
Not covered

Emergency Room

In-network:
You pay $250 copay

Out-of-network:
You pay $250 copay

Emergency Room

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Emergency Room

In-network:
You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)

Out-of-network:
You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)

Emergency Room

In-network:
You pay $250 copay

Out-of-network:
You pay $250 copay

Emergency Room

In-network:
You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)

Out-of-network:
You pay $250 copay (Copay waived if admitted to hospital on inpatient basis)

Urgent Care

In-network:
Your cost will depend on how the provider is contracted and how the claim is billed (Emergency: $250, Urgent Care: $75, Primary Care: $30)

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Urgent Care

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Urgent Care

In-network:
you pay a $30 copay (Must be affiliated with medical group or Referral required)

Out-of-network:
Not covered

Urgent Care

In-network:
Your cost will depend on how the provider is contracted and how the claim is billed (Emergency: $250, Urgent Care: $75, Primary Care: $30)

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Urgent Care

In-network:
you pay a $30 copay (Must be affiliated with medical group or Referral required)

Out-of-network:
Not covered

Inpatient Hospitalization

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay a $400 copay, then 40% (after deductible)
Plan pays 60%

Inpatient Hospitalization

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay a $400 copay, then 40% (after deductible)
Plan pays 60%

Inpatient Hospitalization

In-network:
you pay $750 copay/day ($3,000/Calendar Year)

Out-of-network:
Not covered

Inpatient Hospitalization

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay a $400 copay, then 40% (after deductible)
Plan pays 60%

Hospitalization

In-network:
you pay $750 copay/day ($3,000/Calendar Year)

Out-of-network:
Not covered

Outpatient Surgery

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Outpatient Surgery

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Outpatient Surgery

In-network:
you pay $500 copay then plan pays 100%

Out-of-network:
Not covered

Outpatient Surgery

In-network:
You pay 20% (after deductible)
Plan pays 80%

Out-of-network:
You pay 40% (after deductible)
Plan pays 60%

Outpatient Surgery

In-network:
you pay $500 copay then plan pays 100%

Out-of-network:
Not covered

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

Yes (exceptions may be made in an emergency)

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

Yes (exceptions may be made in an emergency)

Do you need a referral to a specialist?

Yes

Do you need a referral to see a specialist?

Do you need a referral to a specialist?

Yes

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Yes

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Can I use a Health Care Flexible Spending Account (FSA)?

Yes

Can I use a Health Care Flexible Spending Account (FSA)?

Yes

Can I use a Health Care Flexible Spending Account (FSA)?

Yes

Can I use a Health Care Flexible Spending Account (FSA)?

Yes

Prescription Drug

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

***Specialty drugs are limited to 30 day supply

Prescription Drug

Retail (Up to 31-day supply)
In- or out-of-network*:
Generic: $15 copay
Brand (Formulary): 30%
($50 maximum copay)
Brand (Non-Formulary): 50%
($75 maximum copay)
Select oral contraceptives: $0

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

**Specialty drugs are limited to 30 day supply

Prescription Drug

Retail (Up to 31-day supply)
In-network:
Generic: $15 copay
Brand** (Formulary): 30%
($50 maximum copay)
Brand** (Non-Formulary): 50%
($75 maximum copay)
Select oral contraceptives: $0

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

***Specialty drugs are limited to 30 day supply

Prescription Drug

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

***Specialty drugs are limited to 30 day supply

Prescription Drug

Retail (Up to 31-day supply)
In-network:
Generic: $15 copay
Brand** (Formulary): 30%
($50 maximum copay)
Brand** (Non-Formulary): 50%
($75 maximum copay)
Select oral contraceptives: $0

*Out-of-network is covered at 75% of contracted pharmacy amount after the appropriate copay.

***Specialty drugs are limited to 30 day supply

Contributions

Annual base salary $67,000 or Less
EE only: $195.11
EE + spouse/domestic partner/civil union partner: $619.41
EE + child(ren): $415.01
Family: $703.01

Annual base salary $67,001 - $95,000
EE only: $213.69
EE + spouse/domestic partner/civil union partner: $710.77
EE + child(ren): $487.78
Family: $763.41

Annual base salary $95,001 +
EE only: $232.28
EE + spouse/domestic partner/civil union partner: $800.58
EE + child(ren): $562.11
Family: $853.22

Contributions

Annual base salary $67,000 or Less

Employee only: $171.55
Employee + spouse/domestic partner/civil union partner: $544.49
Employee + child(ren): $364.24
Employee + family: $617.84

Annual base salary $67,001 - $95,000

Employee only: $187.72
Employee + spouse/domestic partner/civil union partner: $625.30
Employee + child(ren): $428.88
Employee + family: $671.29

Annual base salary $95,001 +

Employee Only: $203.87
Employee + spouse/domestic partner/civil union partner: $703.62
Employee + Child(ren): $494.77
Employee + Family: $749.61

Contributions

Annual base salary $67,000 or Less

Employee only: $161.26
Employee + spouse/domestic partner/civil union partner: $511.82
Employee + child(ren): $342.39
Employee + family: $580.77

Annual base salary $67,001 - $95,000

Employee only: $176.46
Employee + spouse/domestic partner/civil union partner: $587.78
Employee + child(ren): $403.15
Employee + family: $631.01

Annual base salary $95,001 +

Employee Only: $191.64
Employee + spouse/domestic partner/civil union partner: $661.40
Employee + Child(ren): $465.08
Employee + Family: $704.63