Background Information
Outpatient Services Inpatient Services
Prescription Drug Coverage
Other Services
Health Plan Comparison Chart
The data provided in the chart below is for the 2015 plan year. Compare Again to choose different Health plans and/or comparison points.
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The Health Plan Comparison Chart is provided for informational purposes. As a result of health care reform, there are developing changes that may impact plan final governmental regulatory clarifications on these provisions which may result in changes to certain plan benefits. In the event of a conflict between the Healt Comparison Chart and plan terms, plan terms will govern.
Background Information
East HCN East PPO
Plan Facts
Product name on web site PPO (Participating Provider Option) PPO (Participating Provider Option) Plan description Point of Service Preferred Provider Organization
Member services 1-800-621-7336 1-800-621-7336
Web site bcbsil.com/att bcbsil.com/att
Group ID 00097- For AT&T Benefits Center Use Only
00105- For AT&T Benefits Center Use Only
Cost Sharing
Deductible: Individual/Family Network
$500 Individual; $1,000 Family; combined with MH/SA Non-Network
$1,300 Individual; $2,600 Family; combined with MH/SA
Network
$500 Individual; $1,000 Family; combined with MH/SA Non-Network
$1,300 Individual; $2,600 Family; combined with MH/SA
Annual Out-of-pocket maximum: Individual/Family
Network
$2,000 Individual; $4,000 Family; excludes deductible; combined with MH/SA
Non-Network
$6,000 Individual; $12,000 Family; excludes deductible; combined with MH/SA
Network
$2,000 Individual; $4,000 Family; excludes deductible; combined with MH/SA
Non-Network
$6,000 Individual; $12,000 Family; excludes deductible; combined with MH/SA
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Outpatient Services
East HCN East PPO
Primary Care
Primary doctor office visit Network
90% of Allowable Charges covered after deductible
Non-Network
Network
90% of Allowable Charges covered after deductible
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Specialist office visit Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Outpatient Care
Outpatient surgery Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required
Network
90% of Allowable Charges covered after deductible; preauthorization required Non-Network
60% covered after deductible; subject to Reasonable and Customary limits; preauthorization required; refer to SPD for details
Outpatient laboratory services Network
90% covered after deductible Non-Network
60% covered after deductible; subject to Reasonable and Customary limits
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Outpatient physical therapy Network
90% of Allowable Charges covered after deductible; refer to SPD for details Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; refer to SPD for details
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Outpatient X-ray Network
90% covered after deductible Non-Network
60% covered after deductible; subject to Reasonable and Customary limits
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Family Planning/Maternity Care Office visit: Pre/postnatal Network
Check with Benefits Administrator Non-Network
Check with Benefits Administrator
Network
Check with Benefits Administrator Non-Network
Check with Benefits Administrator In-hospital delivery services Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required
Network
90% of Allowable Charges covered after deductible; preauthorization required Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required
Fertility services Network
90% of Allowable Charges covered after deductible; limited to $20,000 per lifetime; Network, Non-Network and ONA combined; includes Rx preauthorization required Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; limited to
$20,000/lifetime; Network/Non-Network/ONA combined; incl Rx; preauth required
Network Not covered Non-Network Not covered
Preventive Care
Annual physical exam Network
100% of Allowable Charges covered Non-Network
Not covered
Network
100% of Allowable Charges covered Non-Network
Not covered Well-woman exam (includes
pap)
Network
100% of Allowable Charges covered Non-Network
Not covered
Network
100% of Allowable Charges covered Non-Network
Not covered
Mammogram Network
100% of Allowable Charges covered Non-Network
Not covered
Network
100% of Allowable Charges covered Non-Network
Not covered
Pediatric exams Network
100% of Allowable Charges covered Non-Network
Not covered
Network
100% of Allowable Charges covered Non-Network
Not covered
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Inpatient Services
East HCN East PPO
Inpatient Room and Board
Hospital copay or coinsurance Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible, subject to Reasonable and Customary limits
Network
90% of Allowable Charges covered after deductible; preauthorization required Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required
Hospital semi-private room Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required
Network
90% of Allowable Charges covered; after deductible; preauthorization required
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required
Inpatient Care
Inpatient lab and X-ray Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible, subject to Reasonable and Customary limits
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Inpatient physician and surgeon services
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Emergency Care
Emergency room Network
90% of Allowable Charges covered after deductible
Non-Network
For true emergencies, refer to Network provisions; non-emergencies: 60% of
Network
90% of Allowable Charges covered after deductible
Non-Network
For true emergencies: refer to Network provisions; non-emergencies: 60% of
Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Urgent care clinic visit Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
Ambulance services 90% of Allowable Charges covered after deductible; Non-Network - 60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
90% of Allowable Charges covered after deductible; Non-Network - 60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits
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Prescription Drug Coverage
East HCN East PPO
General
Annual prescription deductible Network Not applicable Non-Network Not applicable
Network Not applicable Non-Network Not applicable
Prescription drug Web site caremark.com caremark.com
Prescription drug member services phone number
1-800-378-8851 1-800-378-8851
Prescription drug vendor CVS Caremark CVS Caremark
Annual prescription out-of-pocket maximum
Network
$900 Individual; $1,800 Family; Network copays apply Non-Network Not applicable
Network
$900 Individual; $1,800 Family; Network copays apply Non-Network Not applicable Retail
Retail generic Network
$10 copay; up to 30 day supply; two fill max on maintenance drug, mandatory mail order
Non-Network
25% copay of the Non-Network cost of the drug or the Generic Network copayment, whichever is greater; up to a 30-day supply
Network
$10 copay; up to 30 day supply; two fill max on maintenance drug, mandatory mail order
Non-Network
25% copay of the Non-Network cost of the drug or the Generic Network copayment, whichever is greater; up to a 30-day supply
Retail formulary brand Network
$30 copay; up to 30 day supply; generic avail, pay generic copay + drug cost difference; 2 fill max on
maintenance drug, mandatory mail Non-Network
25% copay of the Non-Network cost of the drug or the Network Preferred copayment, whichever is greater; up to a 30-day supply
Network
$30 copay; up to 30 day supply; generic avail, pay generic copay + drug cost difference; 2 fill max on
maintenance drug, mandatory mail Non-Network
25% copay of the Non-Network cost of the drug or the Network Preferred copayment, whichever is greater; up to a 30-day supply
Retail nonformulary brand Network
$60 copay; up to 30 day supply; generic avail, pay generic copay + drug cost difference; 2 fill max on
maintenance drug, mandatory mail Non-Network
25% copay of the Non-Network cost of the drug or the Network Nonpreferred
Network
$60 copay; up to 30 day supply; generic avail, pay generic copay + drug cost difference; 2 fill max on
maintenance drug, mandatory mail Non-Network
25% copay of the Non-Network cost of the drug or the Network Nonpreferred
copayment, whichever is greater; up to a 30-day supply
copayment, whichever is greater; up to a 30-day supply
Mail Order
Mail order generic $20 copay; up to 90 day supply $20 copay; up to 90 day supply Mail order formulary brand $60 copay; up to 90 day supply; if
generic available, pay generic copay plus drug cost difference
$60 copay; up to 90 day supply; if generic available, pay generic copay plus drug cost difference
Mail order nonformulary brand $120 copay; up to 90 day supply; if generic available, pay generic copay plus drug cost difference
$120 copay; up to 90 day supply; if generic available, pay generic copay plus drug cost difference
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Other Services
East HCN East PPO
Mental Health
Mental Health and Substance Abuse Vendor
ValueOptions ValueOptions
Mental Health and Substance Abuse Web Site
achievesolutions.net/att achievesolutions.net/att
Mental Health and Substance Abuse Phone Number
1-800-554-6701 1-800-554-6701
Mental Health: Outpatient coverage
Network
Office Visit/Other Outpatient: 90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
Office Visit/Other Outpatient: 60% of Allowable Charges covered after deductible; deductible combined with medical and Rx
Network
Office Visit/Other Outpatient: 90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
Office Visit/Other Outpatient: 60% of Allowable Charges covered after deductible; deductible combined with medical and Rx
Mental Health: Inpatient coverage
Network
90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
60% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Network
90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
60% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Substance Abuse
Detox: Outpatient coverage Network
Office Visit/Other Outpatient: 90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
Office Visit/Other Outpatient: 60% of Allowable Charges covered after deductible; deductible combined with medical and Rx
Network
Office Visit/Other Outpatient: 90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
Office Visit/Other Outpatient: 60% of Allowable Charges covered after deductible; deductible combined with medical and Rx
Detox: Inpatient coverage Network
90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
60% of Allowable Charges covered after deductible; deductible and
Out-of-Network
90% covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
60% of Allowable Charges covered after deductible; deductible and
Out-of-Pocket Maximum combined with medical
Pocket Maximum combined with medical
Rehab: Outpatient coverage Network
Office Visit/Other Outpatient: 90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
Office Visit/Other Outpatient: 60% of Allowable Charges covered after deductible; deductible combined with medical and Rx
Network
Office Visit/Other Outpatient: 90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
Office Visit/Other Outpatient: 60% of Allowable Charges covered after deductible; deductible combined with medical and Rx
Rehab: Inpatient coverage Network
90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
60% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Network
90% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Non-Network
60% of Allowable Charges covered after deductible; deductible and Out-of-Pocket Maximum combined with medical
Alternative Care
Chiropractic Network
90% of Allowable Charges covered after deductible; refer to SPD for details Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; refer to SPD for details
Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; refer to SPD for details
Other
Noncustodial home health care Network
90% of Allowable Charges covered after deductible
Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required; refer to SPD for details
Network
90% of Allowable Charges covered after deductible; preauthorization required Non-Network
60% of Allowable Charges covered after deductible; subject to Reasonable and Customary limits; preauthorization required
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The comparison charts are compiled using information that applies to a large number of health plan users and is commonly reported by the health plans. Depen chart type, such as charts for dental plans, certain information and/or sections won't appear because the necessary data isn't available. If you have questions a that isn't covered in the charts, contact the plan's member services department for additional information. Also, keep in mind that the information on access an care is provided by the health plans. Neither AT&T Inc. nor Hewitt Associates is responsible for the accuracy of this information. If there is a discrepancy betwee information displayed on these charts and the official plan documents, the official plan documents will control. AT&T Inc. reserves the right to amend, suspend, the plan(s) or program(s) at any time.
