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PPO/HDHP Covered Services
Regardless of whether you choose the $1000, $500 or $250 deductible PPO option or the HDHP coverage option, you have two levels of coverage. Your coverage level for medical services depends on the type of provider you see to provide your care—a participating provider, or a non-participating provider. Not all services are listed below. Eligible medical services not available at participating providers will be paid at 80% of reasonable and customary charges subject to the annual participating deductible and maximum out-of-pocket limit under your coverage provided you receive prior plan approval. If you use nonparticipating providers, you'll be responsible for any amount over the reasonable and customary charges in addition to the deductibles and coinsurance.

Services Participating
providers		 Nonparticipating
providers
Preventive  (services not subject to deductible)
Routine physical exams 80% of covered expenses
–1 exam each calendar year		 60% of reasonable and customary expenses
Well-child care 80% of covered expenses
–according to schedule		 60% of reasonable and customary expenses
Immunizations 80% of covered expenses
–according to schedule		 60% of reasonable and customary expenses per schedule

Services Participating
providers		 Nonparticipating
providers
Hospital and surgery centers
  Coinsurance is waived at Advocate hospitals
Inpatient care 80% of covered expenses 60% of reasonable and customary expenses
Outpatient surgery 80% of covered expenses 60% of reasonable and customary expenses
Outpatient non-surgical care 80% of covered expenses 60% of reasonable and customary expenses
Emergency room 80% of covered expenses 80% of reasonable and customary expenses
  –after $75 copayment each visit. The copayment is waived if patient is admitted.
Services Participating
providers		 Nonparticipating
providers
Physician
Office visits for treatment of illness or injury 80% of covered expenses 60% of reasonable and customary expenses
Pediatric care 80% of covered expenses 60% of reasonable and customary expenses
Diagnostic lab tests and x-rays 80% of covered expenses 60% of reasonable and customary expenses
In-office allergy treatments and materials 80% of covered expenses 60% of reasonable and customary expenses
Casts, splints, crutches, braces and prosthetic devices 80% of covered expenses 60% of reasonable and customary expenses
Hearing and vision screening exams, eye refractions Not covered Not covered
Hearing and vision exams due to illness or injury 80% of covered expenses 60% of reasonable and customary expenses
Out-patient surgery 80% of covered expenses 60% of reasonable and customary expenses
Infertility 80% of covered expenses 60% of reasonable and customary expenses
In-patient care 80% of covered expenses 60% of reasonable and customary expenses
Services Participating
providers		 Nonparticipating
providers
Other medical services
Chiropractic care 80% of covered expenses 60% of covered expenses
  –medically necessary spinal manipulations per schedule
Home health care 80% of covered expenses 60% of reasonable and customary expenses
Skilled nursing facility 80% of covered expenses 60% of reasonable and customary expenses
Durable medical equipment 80% of covered expenses 60% of reasonable and customary expenses
Physical, occupational and speech therapy 80% of covered expenses 60% of reasonable and customary expenses
Services Participating providers Nonparticipating providers
Behavioral health care
Care must be PRECERTIFIED. Care must be PRECERTIFIED. Please call 1-800-775-0304. Care must be PRECERTIFIED. Please call 1-800-775-0304.
Inpatient 80% of covered expenses 60% of reasonable and customary expenses
  –limited to 45 days each calendar year
Outpatient 80% of covered expenses 60% of reasonable and customary expenses
  –35 sessions per calendar year for both participating and nonparticipating providers; 1 session equals 1 visit; 1 hour maximum per session
Services Participating providers Nonparticipating providers
Alcoholism & chemical dependency
Inpatient
 80% of covered expenses 60% of reasonable and customary expenses
  –limited to 45 days each calendar year
Outpatient
 80% of covered expenses 60% of reasonable and customary expenses
  –35 sessions per calendar year for both participating and nonparticipating providers; 1 session equals 1 visit; 1 hour maximum per session
Prescription drugs
HMO/PPOs Benefits provided through the Advocate Medical Plan Pharmacy Benefit (see Prescription Drug Benefits). After copayment based on drug tier you select—Generic, Preferred Brand Name or Non-Preferred Brand Name—plan pays 100% of covered expenses.
HDHP Benefits provided through HDHP coverage, subject to annual HDHP deductible. If received through a participating pharmacy, plan pays 80% of covered expenses after deductible. If received through a non-participating pharmacy, plan pays 60% of covered charges after deductible. Note: As an HDHP participant, you will receive a Caremark identification card. By showing this card at a participating pharmacy, you will be charged a discounted price for any prescription drugs you purchase.)