1. No category

Description of Coverage (CIP)
Open Access Plan
Tier 1
Tier 2
Tier 3**
None
$300 per enrollee
$400 per enrollee
Individual
$6,600
$6,600
Not applicable
Family
$13,200
Unlimited
None
Coventry Health Care
$13,200
Unlimited
None
Coventry National
Not applicable
Unlimited
None
Out of Network
$250 per admission
$0
$0
$0
$0
20% coinsurance after
$300 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
40% coinsurance of MAC after
$400 copayment
40% coinsurance of MAC
40% coinsurance of MAC
40% coinsurance of MAC
40% coinsurance of MAC
40% coinsurance of MAC
$200 copayment
$200 copayment
$200 copayment
Basic Care (See Provider Directory to select an in-network provider)
Annual deductible*
Out-of-pocket maximum
Tier 1 and Tier 2 cross accumulates. Includes Tier 2 deductible,
Tier 1 and Tier 2 copayments/coinsurance.
Lifetime maximum
Pre-existing condition limitations
Network
Description of Coverage
Hospital
Number of days of inpatient care
Unlimited when authorized
Room and board
Surgeon’s fees
Provider’s visit
Medications
Other miscellaneous charges
Semi-private room, intensive care
Inpatient or outpatient
Except personal comfort items
Emergency
Emergency services (medical conditions of sufficient
severity such that a prudent layperson could reasonably expect the
absence of immediate medical attention to result in serious jeopardy
of the person’s health, serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part)
Emergency post-stabilization services
Waived if admitted as an inpatient for same
condition within 48 hours
Copayment dependent on nature of service
Provider’s Office
Provider’s office visits
Exam, diagnosis, treatment
$30 per office visit
20% coinsurance
40% coinsurance of MAC
Routine physical exams
One per year, includes school physical
and other services listed in our published
preventive guidelines
May require authorization
100% coverage
100% coverage
Covered in network only
$0
$0
$0
100% coverage
20% coinsurance
100% coverage
100% coverage
100% coverage
40% coinsurance of MAC
Covered in network only
Covered in network only
Covered in network only
Surgery and observation; May require authorization
$200
20% coinsurance after 40% coinsurance of MAC after
$200 copayment
$200 copayment
Room and board, ancillary services, care of
child during mother’s stay
Prenatal, delivery and post natal care
See benefit certificate for details on coverage
$250 per admission
20% coinsurance after
$300 copayment
20% coinsurance
20% coinsurance
Diagnostic tests and X-rays
Immunizations
Allergy treatment and testing
Wellness care
Physicals and immunizations covered as
listed above
Medical Services
Outpatient surgery
Maternity care
Hospital care
Provider care
Infertility services
Mental health treatment
$0
Inpatient
$250 per admission
Outpatient
$30 per office visit
Inpatient
$250 per admission
40% coinsurance of MAC after
$400 copayment
40% coinsurance of MAC
40% coinsurance of MAC
20% coinsurance after 40% coinsurance of MAC after
$300 copayment
$400 copayment
20% coinsurance
40% coinsurance of MAC
Substance abuse treatment
Outpatient
Outpatient rehabilitation services
Speech therapy – Pervasive developmental disorders
Up to 60-day treatment period per condition
20 visits per contract year
$30 per office visit
$30 per office visit
$30 per office visit
20% coinsurance after
$300 copayment
20% coinsurance
20% coinsurance
20% coinsurance
40% coinsurance of MAC after
$400 copayment
40% coinsurance of MAC
Covered in network only
Covered in network only
20% coinsurance
20% coinsurance
40% coinsurance of MAC
Other Services (Copays and deductibles for these services may not apply to your out-of-pocket maximums)
Durable medical equipment
Hospice
Home health care
Prescription drugs
Dental services
Vision care
Skilled nursing facility
Ambulance
Chiropractic services
Organ transplants
Prosthetic devices included
See prescription rider in certificate for details
Not covered
Not covered
When authorized
When medically necessary
Out-of-pocket maximum applies
* Annual deductible must be satisfied for all services.
** Maximum allowable charges apply.
For more information, visit our website at chcillinois.com or call 800-431-1211
Policies are administered by Coventry Health Care of Illinois, Inc.
CHCIL_00403 (03/15)
$0
20% coinsurance
40% coinsurance of MAC
$30 per office visit
20% coinsurance
Covered in network only
Administered through the state self insured prescription benefit manager
n/a
n/a
n/a
n/a
n/a
n/a
$0
20% coinsurance
Covered in network only
$0
20% coinsurance
40% coinsurance of MAC
$30 per office visit
20% coinsurance
Covered in network only
$0
20% coinsurance
Covered in network only
Effective July 1, 2015