Summary of Benefits 6/1/2008—5/31/2009 Major Medical Insurance Carrier: BlueCross BlueShield Website: www.bcbsil.com Phone: PPO: 800.541.2763 HMO: 800.892.2803 Preferred Provider Organization (PPO) – Although you have the flexibility to see any doctor or visit any hospital of your choice, you will likely pay significantly less money out of pocket if you use a doctor or hospital that is in the network. For most doctor visits and preventative care visits, you simply pay a copayment at the time of service. You have a great deal of flexibility and choice with a PPO, and can manage your out-of-pocket costs by remaining in network. Preferred Provider Organization (PPO) Blue Choice Select— This option works identically to a standard PPO within a smaller PPO network but with lower premiums. Health Maintenance Organization (HMO) – When selecting this plan, you need to choose a Primary Care Physician (PCP) from a list of network doctors. Your PCP is your “medical coach” and will refer you when you need to see a specialist doctor, fill a prescription, or use any hospital services. As long as you use doctors and hospitals that are part of the HMO network, you should have few out-of-pocket expenses for medical care. Health Maintenance Organization (HMO) Blue Advantage—This option works identically to a standard HMO within a smaller HMO network but with lower premiums. Carrier: MetLife Website: www.metlife.com Phone: 800.942.0854 Preferred Provider Organization (PPO) – While you are able to see any dentist of your choice, you will likely pay less money out of pocket for using dentists in the MetLife network Choice of plan options: PPO In-Network PPO Out-of-Network Individual/Family Deductible $50/$150 $50/$150 Preventive Coinsurance Basic Coinsurance Major Coinsurance 100% 90% 60% 100% 80% 50% Annual Plan Maximum $1,500 $1,500 Orthodontia Coinsurance 60% 50% Orthodontia Lifetime Maximum $1,000 $1,000 Contributions Per Paycheck: You Pay Employee Only Employee + Spouse Employee + Child(ren) Family $2.84 $5.97 $6.82 $10.95 Company Pays $8.51 $17.90 $20.47 $32.84 Choice of plan options: PPO PPO HMO BCBS Network PPO BlueChoice Select HMO Illinois DeductibleIn-Network (Individual/Family) Out-of-Network (Individual/Family) $250/$750 $500/$1,500 $250/$750 $1,000/$3,000 $0 Not Applicable CoinsuranceIn-Network / Out-of-Network 90%/70% 90%/60% 100% Out-of-Pocket Max In-Network (Individual / Family) Out-of-Network (Individual / Family) $750/$2,250 $2,000/$6,000 $1,250/$3,750 $5,000/$15,000 $1,500/$3,000 Not applicable Physician Services (In-Network)Physician Office Visit Well Adult / Well Child Specialist Diagnostic Lab & X-Ray $20 copay $20 copay $20 copay Ded., then 90% $20 copay $20 copay $20 copay Ded., then 90% $20 copay $20 copay $20 copay $20 copay Inpatient Hospital Deductible (In-Network/Out-of-Network) $0/$300 $0/$300 $0 Emergency Room $75 copay $75 copay $75 copay Prescription Drugs (Generic/Formulary/Non-Formulary) Copays: $15/30/50 Copays: $15/30/50 Copays: $15/30/50 Lifetime Maximum $5,000,000 $5,000,000 Unlimited HMO BlueAdvantage HMO $0 Not Applicable 100% $1,500/$3,000 Not applicable $20 copay $20 copay $20 copay $20 copay $0 $75 copay Copays: $15/30/50 Unlimited HR Contact: Mary Beth Szczepanski Phone: 312.698.6086 Email: [email protected]Dental InsuranceVision Insurance Carrier: Ameritas/VSP
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