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BENEFITS AT A GLANCE

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									                            COMMUNITY UNIT SCHOOL DISTRICT 303
                                                      BENEFITS AT A GLANCE
                                     BASIC PPO PLAN                             ENHANCED PPO PLAN
                                                                                                                                  HMOI
                              In-Network            Out-of-Network           In-Network           Out-of-Network
 APPLIES ONLY TO                  Salary                  Salary                Salary                  Salary
 DEDUCTIBLE                  <30,000/>30,000         <30,000/>30,000       <30,000/>30,000         <30,000/>30,000
 Deductible
     Single                    $300/$400                $600/$800             $150/$200                  $300/$400                   $0
     Single + 1                $600/$800              $1,200/$1,600           $300/$400                  $600/$800                   $0
     Family                   $900/$1,200*            $1,800/$2,400*          $450/$600                 $900/$1,200                  $0
 Out-of-Pocket
     Single                       $4,000                  $8,000**              $2,000                     $4,000                   $500
     Single + 1                   $6,000                 $12,000                $4,000                     $8,000                  $1,000
     Family                       $8,000                 $16,000**              $6,000                    $12,000                  $1,500
 Lifetime Maximum                           $1,000,000                                     $1,000,000                            Unlimited
 Hospital/Surgical
 Services
 (incl. mental health)
     Inpatient                80% after ded.           70% after ded.        80% after ded.          70% after ded.                100%
     Outpatient               80% after ded.           70% after ded.        80% after ded.          70% after ded.                100%
     Out of Area              80% after ded.           70% after ded.        80% after ded.          70% after ded.                0%***
 Hospital Deductible                $0                      $300                  $0                       $300             $100/day for 3 days

 Emergency Room              $100 copay then 80% after regular ded.         $100 copay then 80% after regular ded.         100% after $75 copay

 Nursery Charges              80% after ded.           70% after ded.        80% after ded.          70% after ded.                100%

 Chiropractic                   $50 copay              70% after ded.          $50 copay             70% after ded.        100% after $40 copay
                                 $500 maximum/calendar year                      $500 maximum/calendar year                 Requires a Referral
 Physical Therapy               $50 copay              70% after ded.         $50 copay.             70% after ded.        100% after $20 copay
                                 $2,500 maximum/calendar year                   $2,500 maximum/calendar year
 Physician Services
 (incl. mental health)        80% after ded.           70% after ded.        80% after ded.          70% after ded.               100%
    Inpatient                                                                                                            100% after $20 copay for
                              $25 copay for            70% after ded.        $25 copay for           70% after ded.      primary care and $40 for
    Outpatient             primary care and $50                           primary care and $50                                  specialist
                               for specialist                                 for specialist
    Out of Area                            80% after ded.                                80% after ded.                             N/A
 Private Duty Nursing         80% after ded.       70% after ded.            80% after ded.        70% after ded.                   100%
                                   $3,000 annual maximum                           $3,000 annual maximum                        after referral
 Other Services
   Outpatient                 80% after ded.         70% after ded.          80% after ded.         70% after ded.                 100%
   Out of Area                           80% after ded.                                 80% after ded.                             0%***
                           Only required for hospital stays longer than   Only required for hospital stays longer than
 Maternity
                           48 hours for a vaginal delivery or 96 hours    48 hours for a vaginal delivery or 96 hours     Physician will Authorize
 Authorization
                                     for a cesarean section.                        for a cesarean section.
                                Pre-certification is required before all hospital admissions (or within two working days
                             following an emergency admission) and before all scheduled surgeries performed outside the
 Pre-certification
                               doctor’s office. A $200 additional deductible plus 10% coinsurance reduction in benefits   Physician will Authorize
 Penalty****
                                                                      will be applied.
                                              Utilization Management can be reached at: 1-800-572-3089
 *           One person must meet the single deductible before the family deductible is met.
 **          Not to exceed this amount for in or out-of-network.
 ***         Except when emergency treatment is required. You must call your Primary care Physician (PCP) for follow-up care.
 ****        All inpatient hospital admissions or any surgeries must be pre-certified for both PPO plans.




Please Refer to your Summary Plan Description for Further Details                                                                      Plan Year 2010
                                         BASIC PPO PLAN                            ENHANCED PPO PLAN
                                                                                                                                  HMOI
                                 In-Network            Out-of-Network           In-Network         Out-of-Network
 WELLNESS BENEFITS
 Well Baby/                     100% to $500/year       90% to $500/year          100% to          90% to $500/year         100% less $20 copay
 Child Care                           max.                   max.              $500/year max.           max.              per visit for primary care
 Routine Care                                                                                                               100% less $20 copay
                                100% to $500/year       90% to $500/year          100% to          90% to $500/year
                                                                                                                        per visit for primary care $40
                                      max.                   max.              $500/year max.           max.
                                                                                                                                 for specialist
 OTHER BENEFITS (Included in all medical plans)
                                         $5 Generic/$15 Brand/                        $5 Generic/$15 Brand/                $5 Generic/$15 Brand/
                                           $45 Non-Preferred                            $45 Non-Preferred                    $45 Non-Preferred
 Retail Drugs
                                             34 Day Supply                                34 Day Supply                        34 Day Supply
                                          $50 Self-Injectables                         $50 Self-Injectables                 $50 Self-Injectables
                                                                                      $10 Generic/$30 Brand/
                                $10 Generic/$30 Brand/$90 Non-Preferred                                                    $10 Generic/$30 Brand/
 Mail Order Drugs                                                                       $90 Non-Preferred
                                             90 Day Supply                                                                   $90 Non-Preferred
                                                                                          90 Day Supply
 VISION BENEFITS – VISION SERVICE PLAN (VSP) (included in all medical plans)
  Eligible members and/or dependents may select any licensed provider for vision care services. Members who choose to receive services from a Non-
                                      Participating provider will be reimbursed up to the maximum allowance.
                                                 VSP Participating Provider                                  Non-Participating Provider
 Exam
                                                    100% after $10 copay                                       Reimbursed up to $25
 Once every 12 months
 Lenses
     Single Vision                                  100% after $25 copay                                       Reimbursed up to $30
     Bifocal                                        100% after $25 copay                                       Reimbursed up to $35
     Trifocal                                       100% after $25 copay                                       Reimbursed up to $45
 Once every 12 months
 Frames
                                                Covered up to $130 allowance                                   Reimbursed up to $45
 Once every 24 months
                                                Covered up to $130 allowance
 Elective Contact Lenses      (Additional 15% discount applied to contact lens evaluation exam                 Reimbursed up to $105
                                  services, material at doctor’s usual and customary fees)
 Non-Covered Glasses                                    20% discount                                                     N/A
 DENTAL BENEFITS – DELTA DENTAL (Must be elected separately)
                                         Delta Preferred Option                      Delta Premier Managed
                                                                                                                         Non-Delta Network Dentist
                                         PPO Network Dentist                     Fee-for-Service Network Dentist
 Deductible
                                             $50 per individual                            $50 per individual                     $50 per individual
 Applies to B & C
 Calendar Year Max                               $1,500 *                                       $1,500 *                               $1,500 *
 Coverage A
                                          100% of discounted fees                     100% of Usual & Customary             80% of Usual & Customary
 Preventive
 Coverage B
                                          80% of discounted fees                       80% of Usual & Customary             70% of Usual & Customary
 Minor Restorative
 Coverage C
                                          50% of discounted fees                       50% of Usual & Customary             40% of Usual & Customary
 Major Restorative
 “To Go” Benefit                                * Unused portion can be carried over using the “To Go” benefit. See brochure for details.
              Note: A separate calendar year maximum of $1,000 applies to dental implants. This maximum is not part of the “To Go” benefit.
                                            Dental implants are covered under Coverage C, Major Restorative.


                                                    IMPORTANT PHONE NUMBERS
 Lonnie Szalkowski, Benefits Coordinator for District 303                                                          630-377-4815
 BlueCross BlueShield of Illinois
   HMO                                                                                                             800-892-2803
   PPO                                                                                                             800-828-3116
   24/7 Nurseline                                                                                                  800-299-0274
 Delta Dental                                                                                                      800-323-1743
 VSP                                                                                                               800-877-7195
 AmeriFlex                                                                                                         888.868.3539
 Employee Assistance Program (EAP)                                                                                 630-653-4218
 SunLife                                                                                                           800-247-6875



Please Refer to your Summary Plan Description for Further Details                                                                     Plan Year 2010

								
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