Advocate Health Care
Benefits
Medical Benefits

 
Resources Forms

Associate Contributions Dental HMO Dental HMO Copayment Schedule MetLife PDP MetLife PDP with Orthodontia MetLife Dental ID Card MetLife PDP Dental Nomination Card
Disability Certification Disability Council Eligibility Requirements Limited Hours Program Long Term Disability Plan Short Term Disability Plan Social Security Disability Benefits   Vocational Rehabilitation Services   
Affidavit of Domestic Partnership Dependent Coverage    Eligibility    Enrollment Process    Estimated Imputed Income Paying for Benefits   
Account Rules    Eligible Dependent Day Care Expenses    Eligible Health Care Expenses    Reimbursement Process    Tax Advantages   
ActiveHealth® HealthMedia® Healthe You Goes RED Healthe You Awards Healthe TRENDS Know Your Numbers    Questions & Answers    Start! Walking
Coming Soon! Healthe Actions Healthe Breathing Healthe Care Healthe Champion Healthe Eating Healthe Path Healthe Vending
Covered Services FAQs
FAQs  
Optional AD&D Insurance    Optional Life Insurance   
Associate Contributions Deductible Reimbursement Account (DRA) Health Maintenance Organization (HMO) Health Reinbursement Account (HRA) Health Savings Account (HSA) Healthe Futures Account (HFA) High Deductible Health Plan (HDHP) Medicare Part D   Non-Duplication of Benefits   Physician Search PPO/Deductible Reimbursement Plan (PPO/DRP) PPO/DRP and HDHP Covered Services Woman's Health and Cancer Rights Act of 1998  
PTO Sharing/Donation  
Investment Options Vesting Loans and Withdrawals Other Information
Condell Health Network Retirement Plan- Form 5500 Portable Pension Plan    Benefits Update
Primary Benefits   Secondary Discounts Rates  

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PPO/DRP and HDHP Covered Services

Regardless of whether you choose a PPO/DRP coverage 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 100% of covered expenses—1 exam each calendar year 60% of reasonable and customary expenses
Well-child care 100% of covered expenses—according to schedule 60% of reasonable and customary expenses
Immunizations 100% of covered expenses—according to schedule 60% of reasonable and customary expenses per schedule
Services Participating
providers		 Nonparticipating
providers
Hospital and surgery centers
  One-half of 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 $200 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
  —limited to 60 visits per calendar year for all therapy services
Services Participating providers Nonparticipating providers
Behavioral health care
Care must be PRECERTIFIED. Care must be PRECERTIFIED. Please call 800.454.6455.
Inpatient 80% of covered expenses 60% of reasonable and customary expenses
   
Outpatient 80% of covered expenses 60% of reasonable and customary expenses
   
Services Participating providers Nonparticipating providers
Alcoholism & chemical dependency
Inpatient
 80% of covered expenses 60% of reasonable and customary expenses
   
Outpatient
 80% of covered expenses 60% of reasonable and customary expenses
   
Prescription drugs
PPO/DRP or HMO Benefits provided through the Advocate Program (see Prescription 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.)