13
CTPF 2027 NON-MEDICARE HEALTH INSURANCE HANDBOOK
Blue Cross Blue Shield 
HMO Illinois (HMOI)
ANNUAL MEDICAL PLAN YEAR DEDUCTIBLE
None
ADDITIONAL DEDUCTIBLES
None
HOSPITAL SERVICES
Inpatient 
$200    Copay per admission                                          
            (not to exceed 2 copays per year)
Skilled Nursing Facility (non-custodial)
$200 per admit
OUTPATIENT SERVICES
Chemotherapy, Radiation Therapy
$30      Copay
Emergency Room
$125    Copay: PCP notification recommended except   
             in life threatening situation
Lab/X-ray
$30      Copay
Speech, Physical and Occupational Therapy
No copay
Limited to 60 visits per year
Surgery
$175    Copay
Urgent Care
$30      Copay
 Blue Cross Blue Shield PPO
ANNUAL MEDICAL PLAN YEAR DEDUCTIBLE
$1,500   PPO (in network)
$3,000	  Non-PPO (out of network)
ADDITIONAL DEDUCTIBLES
$0           Deductible each PPO hospital admission
$0           Deductible each non-PPO hospital admission   
HOSPITAL SERVICES
Inpatient 
90%        PPO hospital
50%        Non-PPO hospital
Skilled Nursing Facility (non-custodial)
90%        PPO facility
50%        Non-PPO facility
Services must be rendered in a 
BCBS-approved skilled nursing facility.
OUTPATIENT SERVICES
Chemotherapy, Radiation Therapy
90%	      PPO provider 
50%	      Non-PPO provider
Emergency Room
80%       After $200 emergency room deductible,   
              unless admitted
Lab/X-ray
90%	      PPO provider 
50%	      Non-PPO provider
Speech, Physical and Occupational Therapy
90%	       PPO provider 
50%	       Non-PPO provider
Surgery
90%	      PPO provider
50%	      Non-PPO provider
Urgent Care
$50	       Copay PPO provider
50%	      Non-PPO provider

View this content as a flipbook by clicking here.