Health Plan Options.pdf

PDF 450 KB Posted Oct 2, 2023

Attached to: Third-Party Administrative Services for Medical Plan
Solicitation number: 2023-E-01
Issued by: Tazewell County, Illinois

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Written by GovTribe AI · Apr 16, 2025

This document is a Health Care Coverage Highlights summary detailing medical plan options for Tazewell County, Illinois, covering employee medical insurance across four distinct plan types: Traditional PPO Plan, Mid-Level PPO Plan, Qualified PPO Plan, and a Medical Reimbursement Plan. The document comprehensively outlines coverage details for approximately 320 active and retired employees and their dependents, with variations in deductibles, copayments, coinsurance rates, and out-of-pocket maximums for in-network and out-of-network services.

The plans feature graduated coverage levels with individual and family deductibles ranging from $500 to $3,200, and out-of-pocket maximums from $1,300 to $6,000, depending on the selected plan. Key changes from the previous plan include increased emergency room copays from $150 to $300, a standardized $75 urgent care copay, and modifications to in-office physician services cost structures. Prescription drug benefits are also detailed, with varying copayment levels for generic, formulary, and non-formulary medications. The Medical Reimbursement Plan uniquely offers coverage for employees with alternative employer-sponsored medical coverage, reimbursing deductibles, copays, and coinsurance up to a specified maximum benefit amount.

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IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

INDIVIDUAL DEDUCTIBLE $500 $500 $1,000 $1,000 $3,200 $3,200

FAMILY DEDUCTIBLE $1,000 $1,000 $2,000 $2,000 $4,000 $4,000 Calendar Year Maximum

$5,000

PHYSICIAN OFFICE VISIT $25 copayment per visit Deductible, then 20% coinsurance $25 copayment per visit Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance

TELEDOC VIRTUAL OR TELEPHONIC VISIT No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived

URGENT CARE $75 copayment per visit* $75 copayment per visit* $75 copayment per visit $75 copayment per visit Deductible, then 20% coinsurance Deductible, then 20% coinsurance

EMERGENCY ROOM $300 copayment per visit* $300 copayment per visit* $300 copayment per visit $300 copayment per visit Deductible, then 20% coinsurance Deductible, then 20% coinsurance

AMBULANCE Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance

HOSPITALIZATION Deductible, then 20% coinsurance Deductible, then 20% coinsurance

▪ Facility Deductible, then 20% coinsurance Deductible, then 20% coinsurance

Deductible, then 20% coinsurance Deductible, then 20% coinsurance

OUTPATIENT SERVICES & PHYSICIAN CHARGES Deductible, then 20% coinsurance Deductible, then 20% coinsurance

▪ Facility Deductible, then 20% coinsurance Deductible, then 20% coinsurance

▪ Outpatient Physician Surgery Services Deductible, then 20% coinsurance Deductible, then 20% coinsurance

▪ Advanced Imaging, Labs, X-Rays Deductible, then 20% coinsurance Deductible, then 20% coinsurance

PREVENTATIVE CARE No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived

ANNUAL MAMMOGRAM

▪ regardless of diagnosis

COMPREHENSIVE BREAST ULTRASOUNDS

▪ If mammogram demonstrates medical necessity by referring physician

GENETIC TESTING No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived

ROUTINE PRENATAL SERVICES No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived No Charge; Deductible Waived

IN OFFICE PHYSICIAN SERVICES Deductible, then 20% coinsurance Deductible, then 20% coinsurance

▪ X-Ray and Advanced Imaging Services Deductible, then 20% coinsurance Deductible, then 20% coinsurance

▪ Lab Services Deductible, then 20% coinsurance Deductible, then 20% coinsurance

▪ Surgery Services Deductible, then 20% coinsurance Deductible, then 20% coinsurance

ALL OTHER COVERED SERVICES Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance

PRESCRIPTION DRUG BENEFITS

Pharmacy Option:

▪ Generic

▪ Formulary

▪ Non-Formulary and Specialty

Mail Order Option:

▪ Generic

▪ Formulary

▪ Non-Formulary

Prior authorization is required for all scheduled outpatient surgical procedures and advanced medical imaging such as CT, MRI, MRA, PET, nuclear medicine, and nuclear cardiology.

Services performed during a medical emergency do not require prior authorization.

Pre-certification is required for all inpatient hospitalizations - within 48 hours prior to any scheduled inpatient hospitalizations and within 24 hours after an emergency inpatient admission.

CHANGES FROM PREVIOUS PLAN *

1. Authorization required for all advanced imaging services (CT, MRI, MRA, PET, nuclear medicine, nuclear cardiology) and outpatient surgeries.

2. Emergency Room copay increase from $150 to $300 per visit (in-network).

3. Urgent Care has a copay of $75 per visit now instead of subject to the deductible, then 10% coinsurance (in-network).

4. In Office Physician Services (x-ray, advanced imaging, labs, surgery) are now subject to the deductible, 20% coinsurance instead of $25 copay (in-network).

No Charge; Deductible Waived No Charge; Deductible Waived

Deductible, then 20% coinsurance Deductible, then 20% coinsurance

No Charge; Deductible Waived No Charge; Deductible Waived

No Charge; Deductible Waived

Deductible, then 10% coinsurance

Deductible, then 20% coinsurance

QUALIFIED PPO PLAN

$6,000 $6,000

$8,000 $8,000

HEALTH CARE COVERAGE HIGHLIGHTS

▪ Inpatient Services including Inpatient Physician

Charges, Surgery Services, Hospital Care

Deductible, then 20% coinsurance

INDIVIDUAL OUT OF POCKET MAXIMUM $1,300

FAMILY OUT OF POCKET MAXIMUM $2,600

$2,000

$4,000

$1,300

$2,600

$2,000

$4,000

Deductible, then 20% coinsurance

TRADITIONAL PPO PLAN MID-LEVEL PPO PLAN

Deductible, then 20% coinsurance Deductible, then 20% coinsurance

No Charge; Deductible Waived

Deductible, then 20% coinsurance

No Charge; Deductible Waived No Charge; Deductible Waived

Deductible, then 10% coinsurance

Deductible, then 20% coinsurance

Deductible, then 10% coinsurance

Deductible, then 20% coinsurance

Deductible, then 10% coinsurance

Deductible, then 20% coinsurance

Deductible, then 20% coinsurance*

No Charge; Deductible Waived

$100 copayment per drug

Deductible, then 20% coinsurance

MEDICAL

REIMBURSEMENT PLAN

Employees with other employer-sponsored group medical coverage may elect only the

Medical Reimbursement Plan.

Deductibles, copays, and coinsurance under a group medical or drug plan not sponsored by the Employer or other governmental unit participating in the Plan are covered in full up to the maximum benefit amount per individual for expenses incurred in a calendar year. Benefits are paid directly to the covered person when the covered person sends a copy of the other plan's explanation of benefits or a copy of the prescription receipt showing the copay, to the Claims

Administrator.

Chiropractic Year Maximum

$1,500

$100 copayment per drug

$12 copayment per drug

$30 copayment per drug

$50 copayment per drug

$24 copayment per drug

$60 copayment per drug Deductible, then 20% coinsurance

Deductible, then 20% coinsurance

$12 copayment per drug

$30 copayment per drug

$50 copayment per drug

$24 copayment per drug

$60 copayment per drug

File details come from the government source that posted it. Updated Apr 15, 2025.