Advocate Benefits

As part of Advocate�s commitment to flexibility, the Advocate Health Care Medical Preferred Provider Organization Plan (the CoreSource PPO Plan) and the Humana Preferred Provider Organization Plan (the HumanaPPO Plan) offer you two levels of coverage. Under either PPO option, you decide at any time whether to use PPO participating providers or nonparticipating providers.

	*When you use participating providers* �you receive maximum benefits and reduce your out-of-pocket costs.
	*When you use nonparticipating providers* �your benefits are lower, your out-of-pocket costs are higher and there are claim forms to file.

Under either PPO coverage option, there are deductibles and coinsurance amounts to pay. Both PPO coverage options are identical except for the fact that each represents a different network of health care providers. (This is the only difference between these two PPO coverage options, but it is an important factor to take into account if you are interested in PPO coverage.)

If you use participating providers, the PPOs cover eligible expenses at 80%. When you use nonparticipating providers for your medically necessary care, the plans cover most expenses at 60% of the reasonable and customary charges according to the plans' reimbursement schedule.

If you elect coverage under one of the PPOs, you must choose either the $250 deductible option, $500 deductible option or the $1000 deductible option.

Another important feature of the PPO coverage options available to you�the CoreSource PPO and the HumanaPPO�is that both pay preventive care services according to a schedule of benefits without having to meet your deductible first. In other words, benefits for preventive care services are not subject to a deductible. This makes it easier to maintain your family�s health by taking advantage of preventive care services such as immunizations, check ups and screening tests.

Not sure if participating in a PPO is right for you? Here are a few questions you may want to ask yourself:

	Do you prefer to pay a set amount when you see your doctor? In the PPOs you pay a coinsurance fee, which is a percentage of the total cost of the service. In the HMO you pay a set copayment for most services,
	Do you mind paying a deductible before benefits are paid? In the PPOs you must meet an annual deductible before benefits are paid. In the HMO there is no deductible to meet before benefits begin (though a copayment does apply to most covered services).
	Do you need flexibility in terms of which physicians you can see? In the PPOs, you can see any doctor you choose, but benefits are payable at different levels depending on whether the doctor is a member of the PPO's network of participating providers. In the HMO, you must select a primary care physician (PCP), who then coordinates all of your care, including care provided by a specialist. Benefits are only payable if you see your PCP and other HMO physicians to which your PCP provides a referral.

This is a brief description of the CoreSource PPO, which is administered by CoreSource, and the HumanaPPO, which is administered by Humana. This isn't the plan document and doesn't include all of the benefits, limitations and exclusions of the plan. More complete terms of the plan are contained in the certificate of coverage, certificate of insurance or Plan Summary.

For answers to questions about general plan features or claims, contact the plan administrator, CoreSource � by phone at 1-888-212-7385 (7 a.m. to 5 p.m., Monday-Friday), or online at www.coresource.com. See the Benefits Directory for the phone number to call for Behavioral Health precertification and an address and fax number for written correspondence.

PPO deductible options

$250 deductible option (applies to all services except for preventive care)
	Participating providers	Nonparticipating providers
Annual deductibles	$ 250 individual $ 500 family	$ 500 individual $1,000 family
Maximum annual out-of-pocket expense limits	$2,000 individual $4,000 family	$5,000 individual $10,000 family
Maximum lifetime benefit for infertility (not including pharmacy)	$25,000	$25,000
Maximum lifetime benefit	$1,000,000 �unlimited for Advocate hospital charges	$1,000,000

$500 deductible option (applies to all services except for preventive care)
	Participating providers	Nonparticipating providers
Annual deductibles	$ 500 individual $1,000 family	$1,000 individual $2,000 family
Maximum annual out-of-pocket expense limits	$2,000 individual $4,000 family	$5,000 individual $10,000 family
Maximum lifetime benefit for infertility (not including pharmacy)	$25,000	$25,000
Maximum lifetime benefit	$1,000,000 �unlimited for Advocate hospital charges	$1,000,000

$1000 deductible option (applies to all services except for preventive care)
	Participating providers	Nonparticipating providers
Annual deductibles	$1,000 individual $2,000 family	$2,000 individual $4,000 family
Maximum annual out-of-pocket expense limits	$2,000 individual $4,000 family	$5,000 individual $10,000 family
Maximum lifetime benefit for infertility not including pharmacy)	$25,000	$25,000
Maximum lifetime benefit	$1,000,000 �unlimited for Advocate hospital charges	$1,000,000

How the PPOs work

	Non-duplication of benefits applies
	You must first pay the annual deductible amounts before coverage begins for all services except prescription drugs and preventive benefits (to which the deductible does not apply).
	Preventive benefits include those listed under Preventive benefits in the PPO/HDHP covered services section.
	If you elect family coverage, two deductible amounts must be satisfied. However, these deductible amounts can be satisfied through a combination of medical expenses for all covered members of your family. This is known as an aggregate deductible.
	A new deductible must be satisfied each calendar year.
	Hospital emergency room copayments cannot be used toward your annual deductibles or maximum out-of-pocket expense amounts.
	Annual deductibles, charges in excess of reasonable and customary charges, and pharmacy copayments will not apply toward your maximum out-of-pocket expense limits.
	Your portion of reasonable and customary charges will be applied equally toward satisfying participating and non-participating deductibles and maximum out-of-pocket expense amounts. Example: Participating annual deductible = $250 Nonparticipating annual deductible = $500 The first $250 you pay for services, regardless of where you receive services, will go toward satisfying both your participating and nonparticipating deductibles. If you incur future participating expenses, your annual deductible is met. Meanwhile, you only have to pay an additional $250 for services to meet your nonparticipating annual deductible if you choose to go to a nonparticipating provider. This same principle applies to your maximum out-of-pocket amount. Whether you see a participating or non-participating provider, benefits for preventive services are not subject to a deductible.
	When you have the opportunity to use an Advocate facility, Advocate will waive the amount you would otherwise pay�20% copayment under PPO coverage. This waiver will NOT apply to emergency room copayments, nor will it apply to the charges of non-Advocate facilities�even if Advocate does not provide the service you need or if an Advocate facility is busy (�on by-pass�) at the time the service is provided.
	If you use nonparticipating providers, you will be responsible for any amount over the reasonable and customary charges in addition to the deductibles and coinsurance.
	Not all services are listed. Eligible medical services not available at participating providers will be paid at 80% of reasonable and customary charges, subject to the annual deductible and maximum out-of-pocket limit, provided you receive prior plan approval.