2015 Summaries
of Medical Benefits
and Coverage
Glossary of
Health Coverage and
Medical Terms
The University of Chicago is required under Health Care Reform to provide a summary of benefits and coverage (or “SBC”) for each medical plan offered and a list of definitions designed to make it easier for you to compare your medical options.
You are receiving this booklet because you are a current employee of the University and currently participating in, or eligible to participate in, the University of Chicago’s medical plans. This information is provided to help you understand and evaluate your medical choices.
The following SBCs summarize important information about all your medical plan options to help you compare your choices before you enroll and understand your coverage after you enroll. They summarize the key features of the medical plans, such as the covered benefits, cost-sharing provisions, and
coverage limitations and exceptions. The Glossary of Terms defines some of the most common medical and insurance terms. An example showing how deductibles, co-insurance, and out-of-pocket limits work together in a real life situation is also included.
This is only a summary. If you want more details about your coverage and costs, you can get the complete terms in the policy or plan document by contacting each medical plan provider: Maroon Plan: bcbsil.com
Maroon Savings Choice: bcbsil.com HMO Illinois: bcbsil.com
Humana: humana.com UCHP: uchp.uchicago.edu
If you need assistance choosing a medical plan, you may visit decisionsupportsuite.com/UChicago. Simply answer a few questions about your health, your lifestyle, and your medical benefits needs. Then in just a few minutes The Choice is Yours will suggest the medical plan that is right for you based on your responses. Please contact the Benefits Team at 773.702.9634 or benefits@uchicago.edu if you have any questions about this information.
Sincerely,
Michael F. Knitter Assistant Vice President
Benefits and Human Resources Operations
The University of Chicago: Maroon Plan
Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: PPOThis is only a summary.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsil.com or by calling 1-866-390-7772.Important Questions Answers Why this Matters:
What is the overall deductible?
For PPO and Non-PPO
$250 Individual/$600 Family Doesn't apply to certain preventative care.
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other
deductiblesfor specific services?
Yes. $200 deductible for Non-PPO hospital admission. There are no other specific
deductibles.
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
Is there an out–of– pocket limiton my expenses?
Yes. For PPO and Non-PPO
$2,000 Individual/$4,000 Family
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out–of–pocket limit?
Prescription copay, premiums, balanced-billed charges, and health
care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Does this plan use a networkof providers?
Yes. Visit www.bcbsil.com or call
1-866-390-7772 for a list of PPO providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network,
preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to
see a specialist? No. You can see the specialist you choose without permission from this plan. Are there services this
The University of Chicago: Maroon Plan
Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: PPO
Copaymentsare fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use PPO providersby charging you lower deductibles, copayments and coinsurance amounts. CommonMedical Event Services You May Need
Your Cost If You Use a
PPO Provider
Your Cost If You Use a
Non-PPO Provider
Limitations & Exceptions
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or
illness 20% coinsurance 35% coinsurance ---none---
Specialist visit 20% coinsurance 35% coinsurance ---none---
Other practitioner office visit 20% coinsurance 35% coinsurance Limited to 20 visits per condition; muscle manipulations subject to medical necessity review after 20 visits. Preventive
care/screening/immunization No Charge No Charge ---none---
If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 35% coinsurance ---none---
The University of Chicago: Maroon Plan
Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: PPO CommonMedical Event Services You May Need
Your Cost If You Use a
PPO Provider
Your Cost If You Use a
Non-PPO Provider
Limitations & Exceptions
If you need drugs to treat your illness or condition
More information about prescription drug coverageis available at
www.caremark.com.
Generic drugs
$8 copay/ prescription for up to a 30 day supply.
$16 copay/
prescription for up to a 90 day supply.
$8 copay/ prescription for up to a 30 day supply.
$16 copay/
prescription for up to a 90 day supply.
Dispensing limits may apply to certain drugs.
For more information about prescription drug coverage visit www.caremark.com or call 866-873-8632.
Formulary brand drugs
$20 copay/
prescription for up to a 30 day supply. $40 copay/
prescription for up to a 90 day supply.
$20 copay/
prescription for up to a 30 day supply. $40 copay/
prescription for up to a 90 day supply.
Dispensing limits may apply to certain drugs.
For more information about prescription drug coverage visit www.caremark.com or call 866-873-8632.
Non-Formulary brand drugs
$35 copay/
prescription for up to a 30 day supply. $70 copay/
prescription for up to a 90 day supply.
$35 copay/
prescription for up to a 30 day supply. $70 copay/
prescription for up to a 90 day supply.
Dispensing limits may apply to certain drugs.
For more information about prescription drug coverage visit www.caremark.com or call 866-873-8632.
Specialty drugs Covered Covered Coverage based on group policy. Prior authorization may be required.
If you have
outpatient surgery
Facility fee (e.g., ambulatory surgery
center) 20% coinsurance 35% coinsurance ---none---
Physician/surgeon fees 20% coinsurance 35% coinsurance ---none---
If you need
immediate medical attention
Emergency room services 20% coinsurance 20% coinsurance ---none---
Emergency medical transportation 20% coinsurance 20% coinsurance Limited to local ground or air transportation. Urgent care 20% coinsurance 35% coinsurance ---none---
The University of Chicago: Maroon Plan
Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: PPO CommonMedical Event Services You May Need
Your Cost If You Use a
PPO Provider
Your Cost If You Use a
Non-PPO Provider
Limitations & Exceptions If you have a
hospital stay Facility fee (e.g., hospital room) 20% coinsurance 35% coinsurance
$200 deductible per admission for Non-PPO providers.
Physician/surgeon fee 20% coinsurance 35% coinsurance ---none---
If you have mental health, behavioral health, or substance abuse needs
Mental/Behavioral health outpatient
services 20% coinsurance 35% coinsurance ---none--- Mental/Behavioral health inpatient
services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers. Substance use disorder outpatient
services 20% coinsurance 35% coinsurance ---none--- Substance use disorder inpatient
services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers.
If you are pregnant
Prenatal and postnatal care 20% coinsurance 35% coinsurance ---none---
Delivery and all inpatient services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers.
If you need help recovering or have other special health needs
Home health care No Charge No Charge Limited to 120 visits per benefit period; precertification required. Rehabilitation services 20% coinsurance 35% coinsurance Limited to 20 visits per condition;
subject to medical necessity review after 20 visits.
Habilitation services 20% coinsurance 35% coinsurance
Skilled nursing care No Charge No Charge Limited to 120 days per benefit period; precertification required.
Durable medical equipment 20% coinsurance 35% coinsurance
Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).
The University of Chicago: Maroon Plan
Coverage Period: 01/01/2015 - 12/31/2015Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: PPO
Common
Medical Event Services You May Need
Your Cost If You Use a
PPO Provider
Your Cost If You Use a
Non-PPO Provider
Limitations & Exceptions If your child needs
dental or eye care
Eye exam Not Covered Not Covered ---none---
Glasses Not Covered Not Covered ---none---
Dental check-up Not Covered Not Covered ---none---
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Acupuncture
Cosmetic Surgery
Dental Care (Adult)
Hearing Aids
Long-Term Care
Routine Eye Care (Adult)
Routine Foot Care (with the exception of person with diagnosis of diabetes)
Weight Loss Programs
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-866-390-7772. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
Bariatric Surgery
Chiropractic Care
Infertility Treatment
Most coverage provided outside the United States. See www.bcbsil.com
Non-Emergency Care When Traveling Outside the U.S.
Private-Duty Nursing (with the exception of inpatient private duty nursing)
The University of Chicago: Maroon Plan
Coverage Period: 01/01/2015 - 12/31/2015Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: PPO
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross Blue Shield of Illinois at 1-866-390-7772 or visit www.bcbsil.com, or contact the U.S Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit http://insurance.illinois.gov.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-866-390-7772.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-390-7772.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码1-866-390-7772.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-390-7772.
The University of Chicago: Maroon Plan
Coverage Period: 01/01/2015 - 12/31/2015Coverage Examples: Coverage for: All | Plan Type: PPO
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of a well-controlled condition)About these Coverage
Examples:
These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.
Amount owed to providers: $7,540
Plan pays $5,730
Patient pays $1,810 Sample care costs:
Hospital charges (mother) $2,700
Routine obstetric care $2,100
Hospital charges (baby) $900
Anesthesia $900
Laboratory tests $500
Prescriptions $200
Radiology $200
Vaccines, other preventive $40
Total $7,540
Patient pays:
Deductibles $250
Copays $10
Coinsurance $1,400
Limits or exclusions $150
Total $1,810
Amount owed to providers: $5,400
Plan pays $4,310
Patient pays $1,090 Sample care costs:
Prescriptions $2,900
Medical Equipment and Supplies $1,300 Office Visits and Procedures $700
Education $300
Laboratory tests $100
Vaccines, other preventive $100
Total $5,400
Patient pays:
Deductibles $250
Copays $320
Coinsurance $440
Limits or exclusions $80
Total $1,090
Note: These examples are based on individual coverage only.
This is
not a cost
estimator.
Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.
See the next page for
important information about these examples.
The University of Chicago: Maroon Plan
Coverage Period: 01/01/2015 - 12/31/2015Coverage Examples: Coverage for: All | Plan Type: PPO
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
Costs don’t include premiums.
Sample care costs are based on national averages supplied by the U.S.
Department of Health and Human Services, and aren’t specific to a
particular geographic area or health plan.
The patient’scondition was not an excluded or preexisting condition.
All services and treatments started and ended in the same coverage period.
There are no other medical expenses for any member covered under this plan.
Out-of-pocket expenses are based only on treating the condition in the example.
The patient received all care from in-network providers. If the patient had received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage Example helps you see how deductibles,
copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No.
Treatments shown are just examples. The care you would receive for thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No.
Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices yourproviders charge, and the reimbursement your health plan allows.
Can I use Coverage Examples
to compare plans?
Yes.
When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the planprovides.Are there other costs I should
consider when comparing
plans?
Yes.
An important cost is the premiumyou pay. Generally, the lower your
premium, the more you’ll pay in out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.
The University of Chicago: Maroon Savings Choice HSA Plan
Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: HSAThis is only a summary.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsil.com or by calling 1-866-390-7772.Important Questions Answers Why this Matters:
What is the overall deductible?
For PPO
$2,000 Individual/ $4,000 Family For Non-PPO
$4,000 Individual/ $8,000 Family Doesn't apply to certain
preventative care.
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other
deductiblesfor specific services?
Yes. $200 deductible for Non-PPO hospital admission. There are no other specific
deductibles.
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
Is there an out–of– pocket limiton my expenses?
Yes. For PPO
$3,000 Individual/ $6,000 Family For Non-PPO
$6,000 Individual/ $12,000 Family
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out–of–pocket limit?
Premiums, balanced-billed charges and health care this plan doesn’t
cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Does this plan use a networkof providers?
Yes. Visit www.bcbsil.com or call
1-866-390-7772 for a list of PPO providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network,
preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to
see a specialist? No. You can see the specialist you choose without permission from this plan. Are there services this
The University of Chicago: Maroon Savings Choice HSA Plan
Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: HSA
Copaymentsare fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use PPO providersby charging you lower deductibles, copayments and coinsurance amounts. CommonMedical Event Services You May Need
Your Cost If You Use a
PPO Provider
Your Cost If You Use a
Non-PPO Provider
Limitations & Exceptions
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or
illness 20% coinsurance 35% coinsurance ---none---
Specialist visit 20% coinsurance 35% coinsurance ---none---
Other practitioner office visit 20% coinsurance 35% coinsurance Limited to 20 visits per condition; muscle manipulations subject to medical necessity review after 20 visits. Preventive care/screening/immunization No Charge No Charge ---none---
If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 35% coinsurance ---none---
The University of Chicago: Maroon Savings Choice HSA Plan
Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: HSA CommonMedical Event Services You May Need
Your Cost If You Use a
PPO Provider
Your Cost If You Use a
Non-PPO Provider
Limitations & Exceptions
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at
www.caremark.com
Generic drugs
$8 copay /
prescription for up to a 30 day supply. $16 copay / prescription for up to a 90 day supply.
$8 copay /
prescription for up to a 30 day supply. $16 copay /
prescription for up to a 90 day supply.
Copay for Preventative Drugs before and after Deductible is met.
Copay for Non-Preventative Drugs only after Deductible is met.
Dispensing limits may apply to certain drugs.
Formulary brand drugs
$20 copay / prescription for up to a 30 day supply. $40 copay / prescription for up to a 90 day supply.
$20 copay /
prescription for up to a 30 day supply. $40 copay /
prescription for up to a 90 day supply.
Copay for Preventative Drugs before and after Deductible is met.
Copay for Non-Preventative Drugs only after Deductible is met.
Dispensing limits may apply to certain drugs.
Non- Formulary brand drugs
$35 copay / prescription for up to a 30 day supply. $70 copay / prescription for up to a 90 day supply.
$35 copay /
prescription for up to a 30 day supply. $70 copay /
prescription for up to a 90 day supply.
Copay for Preventative Drugs before and after Deductible is met.
Copay for Non-Preventative Drugs only after Deductible is met.
Dispensing limits may apply to certain drugs.
Specialty drugs Covered Covered Coverage based on group policy. Prior authorizatin may be required.
If you have
outpatient surgery
Facility fee (e.g., ambulatory surgery
center) 20% coinsurance 35% coinsurance ---none---
Physician/surgeon fees 20% coinsurance 35% coinsurance ---none---
If you need
immediate medical attention
Emergency room services 20% coinsurance 20% coinsurance ---none---
Emergency medical transportation 20% coinsurance 20% coinsurance Limited to local ground or air transportation. Urgent care 20% coinsurance 35% coinsurance ---none---
The University of Chicago: Maroon Savings Choice HSA Plan
Coverage Period: 01/01/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: HSA CommonMedical Event Services You May Need
Your Cost If You Use a
PPO Provider
Your Cost If You Use a
Non-PPO Provider
Limitations & Exceptions If you have a
hospital stay Facility fee (e.g., hospital room) 20% coinsurance 35% coinsurance
$200 deductible per admission for Non-PPO providers.
Physician/surgeon fee 20% coinsurance 35% coinsurance ---none---
If you have mental health, behavioral health, or substance abuse needs
Mental/Behavioral health outpatient
services 20% coinsurance 35% coinsurance ---none---
Mental/Behavioral health inpatient
services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers. Substance use disorder outpatient services 20% coinsurance 35% coinsurance ---none---
Substance use disorder inpatient services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers.
If you are pregnant
Prenatal and postnatal care 20% coinsurance 35% coinsurance ---none---
Delivery and all inpatient services 20% coinsurance 35% coinsurance $200 deductible per admission for Non-PPO providers.
If you need help recovering or have other special health needs
Home health care No Charge No Charge Limited to 120 visits per benefit period; precertification required. Rehabilitation services 20% coinsurance 35% coinsurance Limited to 20 visits per condition;
subject to medical necessity review after 20 visits.
Habilitation services 20% coinsurance 35% coinsurance
Skilled nursing care No Charge No Charge Limited to 120 days per benefit period; precertification required.
Durable medical equipment 20% coinsurance 35% coinsurance
Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both
purchase and rental equipment (up to the purchase price).
The University of Chicago: Maroon Savings Choice HSA Plan
Coverage Period: 01/01/2015 - 12/31/2015Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: HSA
Common
Medical Event Services You May Need
Your Cost If You Use a
PPO Provider
Your Cost If You Use a
Non-PPO Provider
Limitations & Exceptions If your child needs
dental or eye care
Eye exam Not Covered Not Covered ---none---
Glasses Not Covered Not Covered ---none---
Dental check-up Not Covered Not Covered ---none---
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Acupuncture
Cosmetic Surgery
Dental Care (Adult)
Hearing Aids
Long-Term Care
Routine Eye Care (Adult)
Routine Foot Care (with the exception of person with diagnosis of diabetes)
Weight Loss Programs
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-866-390-7772. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
Bariatric Surgery
Chiropractic Care
Infertility Treatment
Most coverage provided outside the United States. See www.bcbsil.com
Non-Emergency Care When Traveling Outside the U.S.
Private-Duty Nursing (with the exception of inpatient private duty nursing)
The University of Chicago: Maroon Savings Choice HSA Plan
Coverage Period: 01/01/2015 - 12/31/2015Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All |Plan Type: HSA
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross Blue Shield of Illinois at 1-866-390-7772 or visit www.bcbsil.com, or contact the U.S Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit http://insurance.illinois.gov.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-866-390-7772.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-390-7772.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码1-866-390-7772.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-390-7772.
The University of Chicago: Maroon Savings Choice HSA Plan
Coverage Period: 01/01/2015 - 12/31/2015Coverage Examples: Coverage for: All | Plan Type: HSA
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of a well-controlled condition)About these Coverage
Examples:
These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.
Amount owed to providers: $7,540
Plan pays $4,390
Patient pays $3,150 Sample care costs:
Hospital charges (mother) $2,700
Routine obstetric care $2,100
Hospital charges (baby) $900
Anesthesia $900
Laboratory tests $500
Prescriptions $200
Radiology $200
Vaccines, other preventive $40
Total $7,540
Patient pays:
Deductibles $2,000
Copays $0
Coinsurance $1,000
Limits or exclusions $150
Total $3,150
Amount owed to providers: $5,400
Plan pays $2,830
Patient pays $2,570 Sample care costs:
Prescriptions $2,900
Medical Equipment and Supplies $1,300 Office Visits and Procedures $700
Education $300
Laboratory tests $100
Vaccines, other preventive $100
Total $5,400
Patient pays:
Deductibles $2,000
Copays $230
Coinsurance $260
Limits or exclusions $80
Total $2,570
Note: These examples are based on individual coverage only.
This is
not a cost
estimator.
Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.
See the next page for
important information about these examples.
The University of Chicago: Maroon Savings Choice HSA Plan
Coverage Period: 01/01/2015 - 12/31/2015Coverage Examples: Coverage for: All | Plan Type: HSA
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
Costs don’t include premiums.
Sample care costs are based on national averages supplied by the U.S.
Department of Health and Human Services, and aren’t specific to a
particular geographic area or health plan.
The patient’scondition was not an excluded or preexisting condition.
All services and treatments started and ended in the same coverage period.
There are no other medical expenses for any member covered under this plan.
Out-of-pocket expenses are based only on treating the condition in the example.
The patient received all care from in-network providers. If the patient had received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage Example helps you see how deductibles,
copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No.
Treatments shown are just examples. The care you would receive for thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No.
Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices yourproviders charge, and the reimbursement your health plan allows.
Can I use Coverage Examples
to compare plans?
Yes.
When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the planprovides.Are there other costs I should
consider when comparing
plans?
Yes.
An important cost is the premiumyou pay. Generally, the lower your
premium, the more you’ll pay in out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.
The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois
Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL|Plan Type: HMO
Questions: Call 1-800-892-2803 or visit us at www.bcbsil.com.
This is only a summary.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsil.com or by calling 1-800-892-2803.Important Questions Answers Why this Matters:
What is the overall
deductible? $0 See the chart starting on page 2 for your costs for services this plan covers. Are there other
deductiblesfor specific services? No.
You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
Is there an out–of– pocket limiton my expenses?
Yes. $1,500 Individual/$3,000
Family.
The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out–of–pocket limit?
Premiums, balanced-billed charges, and health care this
plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Does this plan use a networkof providers?
Yes. Visit www.bcbsil.com or call 1-800-892-2803 for a list of Participating providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to
see a specialist? Yes. This plan will pay some or all of the costs to see a if you have the plan’s permission before you see the specialistspecialist for covered services but only .
Are there services this
The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois
Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL|Plan Type: HMO
Copaymentsare fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use Participating providersby charging you lower deductibles, copayments and coinsurance amounts. CommonMedical Event Services You May Need
Your Cost If You Use a Participating
Provider
Your Cost If You Use a Non-Participating
Provider
Limitations & Exceptions
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness $10 copay/visit Not Covered
Services or supplies that are not ordered by your Primary Care Physician or Women’s Principal Health Care Provider, except
emergency and routine vision exams, are not covered.
Specialist visit $20 copay/visit Not Covered Referral required. Other practitioner office visit $20 copay/visit Not Covered Referral required. Preventive care/screening/immunization No Charge Not Covered ---none---
The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois
Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL|Plan Type: HMO Common
Medical Event Services You May Need
Your Cost If You Use a Participating
Provider
Your Cost If You Use a Non-Participating
Provider
Limitations & Exceptions
If you need drugs to treat your illness or condition
More information about prescription drug coverageis available at www.bcbsil.com.
Generic drugs
$5 copay /
prescription for up to a 34 day supply. $10 copay / prescription for up to a 90 day supply.
Not Covered Dispensing limit may apply to certain drugs.
Certain women’s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. 34 day retail / 90 day mail.
RX Out-of-Pocket Expense Limit: $5,100 Individual/ $10,200 Family Formulary brand drugs
$15 copay / prescription for up to a 34 day supply. $30 copay / prescription for up to a 90 day supply.
Not Covered
Non-Formulary brand drugs
$30 copay / prescription for up to a 34 day supply. $60 copay / prescription for up to a 90 day supply.
Not Covered
Specialty drugs Covered Not Covered Coverage based on group policy. Prior authorization may be required.
If you have
outpatient surgery Facility fee (e.g., ambulatory surgery center) No Charge Physician/surgeon fees No Charge Not Covered Not Covered Referral required. Referral required.
If you need
immediate medical attention
Emergency room services $75 copay/visit $75 copay/visit Copay waived if admitted. Emergency medical transportation No Charge No Charge Ground transportation only. Urgent care $10 copay/visit Not Covered Must be affiliated with member’s chosen medical group or referral
required.
If you have a
hospital stay Facility fee (e.g., hospital room)
$250 copay/
admission Not Covered Referral required. Physician/surgeon fee No Charge Not Covered Referral required.
The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois
Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL|Plan Type: HMO Common
Medical Event Services You May Need
Your Cost If You Use a Participating
Provider
Your Cost If You Use a Non-Participating
Provider
Limitations & Exceptions
If you have mental health, behavioral health, or substance abuse needs
Mental/Behavioral health outpatient
services $10 copay/visit Not Covered Unlimited visits. Referral required. Mental/Behavioral health inpatient services $250 copay/ admission Not Covered Unlimited days. Referral required. Substance use disorder outpatient services $10 copay/visit Not Covered Unlimited days. Referral required. Substance use disorder inpatient services $250 copay/ admission Not Covered Unlimited days. Referral required.
If you are pregnant Prenatal and postnatal care $10 copay Not Covered
Copay applies for the 1st prenatal
visit only. Delivery and all inpatient services $250 copay/ admission Not Covered ---none---
If you need help recovering or have other special health needs
Home health care No Charge Not Covered Referral required.
Rehabilitation services $10 copay/visit Not Covered 60 treatments combined for all therapies.
Referral required. Habilitation services $10 copay/visit Not Covered
Skilled nursing care $250 copay/ admission Not Covered Excludes custodial care. Referral required.
Durable medical equipment No Charge Not Covered
Referral required.
Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice service No Charge Not Covered Inpatient copay may apply. Referral required.
The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois
Coverage Period: 01/01/2015 – 12/31/2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL|Plan Type: HMO
Common
Medical Event Services You May Need
Your Cost If You Use a Participating
Provider
Your Cost If You Use a Non-Participating
Provider
Limitations & Exceptions
If your child needs dental or eye care
Eye exam No Charge Not Covered Limited to one exam every 12 months at participating providers. Glasses Covered Not Covered $75 allowance once every 24 months at participating providers.
Dental check-up Not Covered Not Covered ---none---
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Cosmetic Surgery
Custodial care
Dental care (Adult)
Hearing aids
Long-term care
Non-emergency care when traveling outside the U.S
Private-duty Nursing
Routine foot care (with the exception of person with diagnosis of diabetes)
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
Acupuncture
Bariatric surgery
Chiropractic care
Infertility treatment
Most coverage provided outside the United States. See www.bcbsil.com.
Routine eye care (Adult)
Weight Loss (except when non-medically supervised)
The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois
Coverage Period: 01/01/2015 – 12/31/2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL|Plan Type: HMO
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-892-2803. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Illinois at 1-800-892-2803 or visitwww.bcbsil.com, or contact the U.S Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit
http://insurance.illinois.gov.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-892-2803.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-892-2803.
Chinese (中文): 如果需要中文的帮助,请拨打这个号码 1-800-892-2803.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-892-2803.
The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois
Coverage Period: 01/01/2015 – 12/31/2015
Coverage Examples Coverage for: ALL| Plan Type: HMO
Questions: Call 1-800-892-2803 or visit us at www.bcbsil.com.
Having a Baby
(normal delivery)
Managing Type 2 Diabetes
(routine maintenance of a well-controlled condition)About these Coverage
Examples:
These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.
Amount owed to providers: $7,540
Plan pays $7,120
Patient pays $420
Sample care costs:
Hospital charges (mother) $2,700
Routine obstetric care $2,100
Hospital charges (baby) $900
Anesthesia $900
Laboratory tests $500
Prescriptions $200
Radiology $200
Vaccines, other preventive $40
Total $7,540
Patient pays:
Deductibles $0
Copays $270
Coinsurance $0
Limits or exclusions $150
Total $420
Amount owed to providers: $5,400
Plan pays $5,020
Patient pays $380
Sample care costs:
Prescriptions $2,900
Medical Equipment and Supplies $1,300 Office Visits and Procedures $700
Education $300
Laboratory tests $100
Vaccines, other preventive $100
Total $5,400
Patient pays:
Deductibles $0
Copays $300
Coinsurance $0
Limits or exclusions $80
Total $380
This is
not a cost
estimator.
Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.
See the next page for
important information about these examples.
The University of Chicago HMOI: Blue Cross and Blue Shield of Illinois
Coverage Period: 01/01/2015 – 12/31/2015
Coverage Examples Coverage for: ALL| Plan Type: HMO
Questions: Call 1-800-892-2803 or visit us at www.bcbsil.com.
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
Costs don’t include premiums.
Sample care costs are based on national averages supplied by the U.S.
Department of Health and Human Services, and aren’t specific to a
particular geographic area or health plan.
The patient’scondition was not an excluded or preexisting condition.
All services and treatments started and ended in the same coverage period.
There are no other medical expenses for any member covered under this plan.
Out-of-pocket expenses are based only on treating the condition in the example.
The patient received all care from in-network providers. If the patient had received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage Example helps you see how deductibles,
copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No.
Treatments shown are just examples. The care you would receive for thiscondition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No.
Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices yourproviders charge, and the reimbursement your health plan allows.
Can I use Coverage Examples
to compare plans?
Yes.
When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the planprovides.Are there other costs I should
consider when comparing
plans?
Yes.
An important cost is the premiumyou pay. Generally, the lower your
premium, the more you’ll pay in out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.
Humana, Inc.: University of Chicago IL Platinum HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:Coverage Period: 1/1/201Individual + Family|Plan Type:5 – 12/31/201HMO5
Questions: Call 1-800-448-6262 or visit us at www.humana.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
This is only a summary.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.humana.com or by calling 1-800-448-6262.Important Questions Answers Why this Matters:
What is the overall
deductible?
$0
$0
person family/
See the chart starting on page 2 for your costs for services this plan covers. Are there other deductiblesfor specific services? No You don’t have to meet starting on page 2 for other costs for services this plan coversdeductibles for specific services, but see the chart . Is there an out–of–pocket
limiton my expenses? Yes, for participating providers
$1,500
person/ $3,000
familyThe out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out–of–pocket limit?
Premiums, balance-billed charges, Rx, vision care, and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the medical plan out–of–pocket limit.
Is there an overall annual
limiton what the plan pays? No The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a networkof providers?
Yes. See www.humana.com or call 1-800-448-6262 for a list of Network providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a
specialist? Yes.
This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.
Are there services this plan
Humana, Inc.: University of Chicago IL Platinum HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:Coverage Period: 1/1/201Individual + Family|Plan Type:5 – 12/31/201HMO5
Questions: Call 1-800-448-6262 or visit us at www.humana.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
Copaymentsare fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowed amountfor the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovidercharges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providersby charging you lower deductibles, copayments and coinsurance amounts.Common
Medical Event Services You May Need
Your Cost If You Use an In-network
Provider
Your Cost If You Use an Out-of-network
Provider Limitations & Exceptions
If you visit a health care provider’s office or clinic
Primary care visit to treat an
injury or illness $10 copay/visit Not covered
---none---Specialist visit $20 copay/visit Not covered Primary Care Physician’s referral is
required. Other practitioner office visit $20 copay/visit Not covered
Preventive
care/screening/immunization No charge Not covered ---none--- If you have a test
Diagnostic test (x-ray, blood
work) No charge Not covered ---none---
Humana, Inc.: University of Chicago IL Platinum HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:Coverage Period: 1/1/201Individual + Family|Plan Type:5 – 12/31/201HMO5
Questions: Call 1-800-448-6262 or visit us at www.humana.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
Common
Medical Event Services You May Need
Your Cost If You Use an In-network
Provider
Your Cost If You Use an Out-of-network
Provider Limitations & Exceptions
If you need drugs to treat your illness or condition
More information about prescription drug coverageis available at
www.humana.com
Generic drug $5 copay retail $10 copay mail Drug copay plus 30% coinsurance for retail prescriptions.
Mail order prescriptions not covered.
Retail prescription covers up to a 30-day supply.
Mail order prescription covers up to a 90-day supply.
Preferred brand drugs $15 copay retail $30 copay mail Non-preferred brand drugs $30 copay retail $60 copay mail
Specialty Drugs Included above Prior authorization required.
If you have
outpatient surgery
Facility fee (e.g., ambulatory
surgery center) No charge Not covered Primary Care Physician’s referral is
required.
Physician/surgeon fees No charge Not covered
If you need
immediate medical attention
Emergency room services $75 copay/visit $75 copay/visit Non-emergent emergency room visits are not covered. Emergency medical
transportation No charge No charge ---none---
Urgent care $20 copay/visit Not covered Primary Care Physician’s referral is required.
If you have a
hospital stay Facility fee (e.g., hospital room)
$100 copay for the first
three days/admission Not covered Primary Care Physician’s referral is required.
Humana, Inc.: University of Chicago IL Platinum HMO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:Coverage Period: 1/1/201Individual + Family|Plan Type:5 – 12/31/201HMO5
Questions: Call 1-800-448-6262 or visit us at www.humana.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
Common
Medical Event Services You May Need
Your Cost If You Use an In-network
Provider
Your Cost If You Use an Out-of-network
Provider Limitations & Exceptions
If you have mental health, behavioral health, or substance abuse needs
Mental/Behavioral health
outpatient services $10 copay/visit Not covered ---none--- Mental/Behavioral health
inpatient services $100 copay for the firstthree days/admission Not covered Preauthorization required. Substance use disorder outpatient
services $20 copay/visit Not covered ---none---
Substance use disorder inpatient
services $100 copay for the firstthree days/admission Not covered Preauthorization required. If you are pregnant Prenatal and postnatal care
$20 copay, first visit
only Not covered
Member can self-refer to OB/GYN in the Primary Care Physician’s affiliated group.
Delivery and all inpatient services $100 copay for the first three days/admission Not covered Primary Care Physician notification is recommended.
If you need help recovering or have other special health needs
Home health care No charge Not covered Maximum 60 days per calendar
year; Primary Care Physician’s referral is required.
Rehabilitation services No charge Not covered
Habilitation services No charge Not covered
Skilled nursing care No charge Not covered Maximum 100 days per calendar
year; Primary Care Physician’s referral is required.
Durable medical equipment No charge Not covered
Hospice service No charge Not covered Maximum year; Primary Care Physician’s 180 days per calendar referral is required.
If your child needs dental or eye care
Eye exam $10 copay Not covered
When services are rendered by an EyeMed participating provider. Glasses $100 allowance plus 20% discount off
balance over $100 Not covered