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Benefits • Medical - Standard PPO

The Standard PPO plan offers flexibility to see any health care provider you choose, however when you go to an in-network BlueCross BlueShield provider you are going to receive services at a negotiated discounted fee.

Resources

Benefit Handbooks

2009 Benefits Guide

Medical Coverages & Limitations

Prescription Drug Coverage

Benefit Vendor Directory

Medical Plan Decision Toolkit

Terms to Know

Eligibility Information

Price Sheets FT / PT

To locate PPO providers contact BCBS Customer Service at 1-866-563-8366 or online at www.bcbsil.com/foundations (click on Network Providers).

See the Standard Plan Benefit Handbook for a complete summary of benefits.

	Monthly Premiums	Annual Deductibles	Annual Out-of-Pocket Maximums In Network	Annual Out-of-Pocket Maximums Out of Network
Employee	$31	$1,000	$3,000	$4,000
Employee + Child(ren)	$101	$2,000	$6,000	$8,000
Employee + Spouse/DP*	$84	$2,000	$6,000	$8,000
Family	$172	$2,000	$6,000	$8,000

*DP = Domestic Partner

Pre-existing condition exclusion	None
Out-of-Pocket Expenses	In-Network	Out-of-Network
Deductible	Individual $1,000; Family $2,000 maximum
Annual Out-of-Pocket Maximum (includes deductible)	$3,000 Individual $6,000 Family	$4,000 Individual $8,000 Family
Benefits	In-Network	Out-of-Network
Coinsurance (paid after deductible) applies to all professional services except as noted below	You Pay 20%	You Pay 40%
Office visit copays (Copays do not apply to deductible or out-of-pocket maximum)	You pay 35%	Subject to deductible & coinsurance
Labwork / Professional Services	Subject to deductible & coinsurance
Emergency Room Visit Copayment	Subject to deductible & coinsurance
Wellness Benefit (not subject to deductible)	100% up to $750 annually
Maximum Lifetime Benefit	Unlimited

Coverage through Caremark network pharmacy or mail order only	Retail (30-day supply)	Retail (90-day supply)	Mail Order (90-day supply)
Generic Copay Preferred Brand Copay Non-Preferred Brand Copay	$10 $35 $60	$30 $90 $180	$20 $90 $150

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