auth Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2020 – 06/30/2021 Teachers’ Retirement Insurance Program: HEALTHLINK OPEN ACCESS III Coverage for: Individual + Family | Plan Type: OAP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.illinois.gov/cms. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (800) 624-2356 to request a copy. Important Questions Answers Why This Matters: What is the overall $0/individual for Tier I Generally, you must pay all of the costs from providers up to the deductible amount before deductible? Providers. $300/individual for this plan begins to pay. If you have other family members in this plan, they have to meet their Tier II Network Providers. own deductible before the plan begins to pay. $400/individual for Out-of- Network Providers. Are there services Yes. Preventive care for Tier I This plan covers some items and services even if you haven’t yet met the deductible amount. covered before you and Tier II Network Providers. But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible? services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. There are no other specific You must pay all of the costs for these services up to the specific deductible amount before deductibles for deductibles. this plan begins to pay for these services. specific services? What is the out-of- $6,600/individual or The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for this $13,200/family for Tier I other family members in this plan, they have to meet their own out-of-pocket limits until the plan? Providers and Tier II Network overall family out-of-pocket limit has been met. Providers combined. Unlimited for Out-of-Network Providers. What is not included Premiums, Balance-Billing Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket charges, and Health Care this limit? plan doesn't cover. Will you pay less if Yes, HealthLink Open Access. You pay the least if you use a provider in Tier I. You pay more if you use a provider in Tier II. you use a network See www.healthlink.com or call You will pay the most if y250u use an out-of-network provider, and you might receive a bill provider? (800) 624-2356 for a list of from a provider for the difference between the provider’s charge and what your plan pays network providers. (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral No. This plan will pay some or all of the costs to see a specialist without a referral. to see a specialist? * For more information about limitations and exceptions, see plan or policy document at https://www.illinois.gov/cms. 1 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Out-of-Network Common Tier I Provider Tier II Provider Limitations, Exceptions, & Services You May Need Provider Medical Event (You will pay the (You will pay Other Important Information (You will pay the least) more) most) Primary care visit to treat an $20 40% coinsurance 20% coinsurance --------none-------- injury or illness copayment/visit of MAA $20 copayment 40% coinsurance If you visit a Specialist visit 20% coinsurance --------none-------- /visit of MAA health care provider’s office You may have to pay for services that aren't preventive. Ask your or clinic Preventive care/screening/ No charge No charge Not covered provider if the services needed are immunization preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood 40% coinsurance No charge 20% coinsurance --------none-------- work) at Lab or Doctor’s Office of MAA If you have a test 40% coinsurance Imaging (CT/PET scans, MRIs) No charge 20% coinsurance Pre-authorization required. of MAA $10 copayment $10 copayment /prescription /prescription (retail), $20 (retail), $20 copayment copayment See Summary Plan Tier I - Typically Generic /prescription (mail /prescription (mail description If you need order)and $10 order)and $10 Preventive Prescription Drugs – drugs to treat copayment/prescri copayment/prescri $0. Retail is 30 day supply. Mail your illness or ption (Maintenance ption (Maintenance order is 90 day supply. condition Choice) Choice) Maintenance Choice is a 90 day More information $20 copayment $20 copayment supply for chronic conditions about /prescription /prescription filled at through CVS Caremark prescription (retail), $40 (retail), $40 mail service or at any CVS drug coverage is copayment copayment Tier II - Typically Preferred / See Summary Plan Pharmacy location. See Summary available at /prescription (mail /prescription (mail Brand description Plan description. www.cvs.com order)and $20 order)and $20 copayment/prescri copayment/prescri ption (Maintenance ption (Maintenance Choice) Choice) Tier III - Typically Non- $40 copayment $40 copayment See Summary Plan Preferred / Specialty Drugs /prescription /prescription description * For more information about limitations and exceptions, see plan or policy document at https://www.illinois.gov/cms 2 of 8 What You Will Pay Out-of-Network Common Tier I Provider Tier II Provider Limitations, Exceptions, & Services You May Need Provider Medical Event (You will pay the (You will pay Other Important Information (You will pay the least) more) most) (retail), $80 (retail), $80 copayment copayment /prescription (mail /prescription (mail order)and $40 order)and $40 copayment/prescri copayment/prescri ption (Maintenance ption (Maintenance Choice) Choice) Tier IV - Typically Specialty See Summary Plan Not Applicable Not Applicable Drugs description $150 copayment $150 copayment Facility fee (e.g., ambulatory $150 copayment /visit then 40% /visit then 20% --------none-------- If you have surgery center) /visit coinsurance of coinsurance outpatient MAA surgery 40% coinsurance Physician/surgeon fees No charge 20% coinsurance --------none-------- of MAA $200 copayment $200 copayment Covered as In- Emergency room care Copay waived if admitted. If you need /visit /visit Network immediate Emergency medical No charge No charge No charge --------none-------- medical transportation attention $20 copayment 40% coinsurance Urgent care 20% coinsurance --------none-------- /visit of MAA $400 copayment $300 copayment $250 copayment /admission then Pre-authorization required for Facility fee (e.g., hospital room) /admission then /admission 40% coinsurance Out-of-Network care. If you have a 20% coinsurance hospital stay of MAA 40% coinsurance Physician/surgeon fees No charge 20% coinsurance --------none-------- of MAA If you need Office Visit Office Visit mental health, $20 copayment Office Visit 40% coinsurance Office Visit behavioral /visit 20% coinsurance of MAA Other --------none-------- Outpatient services health, or Other Outpatient Other Outpatient Outpatient Other Outpatient substance abuse $20 copayment 20% coinsurance 40% coinsurance --------none-------- services /visit of MAA * For more information about limitations and exceptions, see plan or policy document at https://www.illinois.gov/cms 3 of 8 What You Will Pay Out-of-Network Common Tier I Provider Tier II Provider Limitations, Exceptions, & Services You May Need Provider Medical Event (You will pay the (You will pay Other Important Information (You will pay the least) more) most) Pre-authorization required for $400 copayment Out-of-Network care; if not $300 copayment $250 copayment /admission then obtained, there will be a reduction Inpatient services /admission then /admission 40% coinsurance in benefits of a $500 penalty per 20% coinsurance of MAA hospital confinement, course of treatment or therapy. $50 copayment / 20% coinsurance 40% coinsurance Office visits pregnancy of MAA Maternity care may include tests Childbirth/delivery professional Included with 20% coinsurance 40% coinsurance and services described elsewhere If you are services Office visit copay of MAA in the SBC (i.e. ultrasound.) Pre- pregnant $400 copayment authorization required for Out-of- $300 copayment Childbirth/delivery facility $250 copayment /admission then Network care or for all Tiers if /admission then services /admission 40% coinsurance longer then 48/96 hour stays 20% coinsurance of MAA $15 copayment Home health care 20% coinsurance Not covered --------none-------- /visit $20 copayment 40% coinsurance Rehabilitation services 20% coinsurance If you need help /visit of MAA Pre-authorization required. See recovering or $20 copayment 40% coinsurance Summary Plan Description Habilitation services 20% coinsurance have other /visit of MAA special health needs Skilled nursing care No charge