Chicago
(HMO)™ H3822-001
(HMO-POS)℠ H3822-007
(PPO) H8634-016
(PPO)℠ H8634-008
(HMO)℠ H8547-001
In-Network
Out-of-Network
In-Network
In-Network
In-Network
Out-of-Network
Plan Premium
$0
$0
$0
$0
$0
Doctors Office Visits
Primary Care Provider
$0 copay
$0 copay
$60 copay
$0 copay
$35 copay
$25
$35 copay
$0 copay
Specialist
$25 copay
$35 copay
$75 copay
$50 copay
$55 copay
$50 copay
$55 copay
$25 copay
Maximum Out-of-Pocket
$2,950
$3,450
No Limit
$3,900
$11,300
$6,900
$11,300
$2,950
Inpatient Hospital Copay
$225 copay per day for days 1-7 and $0 copay per day for days 8-90
$220 copay per day for days 1-7
40% coinsurance
$320 copay per day for days 1-6
50% coinsurance
$320 copay per day for days 1-6
50% coinsurance
$225/day (days 1-7)
Retail Preferred Pharmacy
$0/$8/$39/$93/$33%
Full coverage for Tier 1 gap
Full coverage for Tier 1 gap
$0-$10/$10-$20/$47/$100/33%
Full coverage for Tier 1 gap
Full coverage for Tier 1 gap
$0-$10/$10-$20/$47/$100/28%
Full coverage of Tier 1 gap
Full coverage of Tier 1 gap
$0-$10/$10-$20/$47/$100/28%
Full coverage for Tier 1 gap
Full coverage for Tier 1 gap
$0-$10/$10-$20/$47/$100/33%
Full coverage for Tier 1 gap
Full coverage for Tier 1 gap
Prescription Drug Deductible
$0 Deductible
$0 Deductible
$250 (Tiers 4-5)
$250 (Tiers 4-5)
$0 Deductible
Extra Health & Wellness Benefits
Optional Supplemental Benefits Premium
N/A
$23.90
$32.20
$32.20
N/A
Dental
Preventive
*$0 copay per vist; 2 exams, 2 cleanings, 1 xray
Optional Supplemental Available
Optional Supplemental Available
Optional Supplemental Available
$0 copay 2 exams, 2 cleanings, 1 X-ray
Comprehensive
$1,000 Annual Maximum
$1,000 comprehensive dental allowanc
Vision
Eye Exam
$0 copay
$0 copay (routine) Eye Wear 1 per year
Not Covered
Optional Supplemental Available
Optional Supplemental Available
Optional Supplemental Available
Optional Supplemental Available
$0 copay (routine) 1 per year
Eye Wear
$100 per year maximum
$0 copay (routine) 1 per year
$40 yearly allowance
$0 copay (routine) 1 per year
$40 yearly allowance
$100 yearly allowance
Hearing Aids
$699 copay Advanced $999 copay Premium
Optional Supplemental Available
Optional Supplemental Available
Optional Supplemental Available
$699 Advanced $999 Premium per ear per year
Over-The-Counter (OTC) Purchase Allowance
$50 quarterly
$75 quarterly
Not Covered
Not Covered
$75 quarterly
Silver Sneakers Fitness Program
✓
✓
✓
✓
✓
24/7 Nurse Line
✓
✓
✓
✓
✓
Transportation
$0 copay/up to 12 one-way trips every year to plan-approved locations
24 one-way trips
Not Covered
Not Covered
Not Covered
12 one-way trips
Rewards
✓
✓
✓
✓
✓
Telehealth
$0 copay Urgent Care Only
$0 copay Urgent Care Only
$0 copay Urgent Care Only
$0 copay Urgent Care Only
$0 copay Urgent Care Only
