Loyola University Chicago

Lifetime Comprehensive Major Medical Coverage Maximum

$2,000,000

Annual Deductible (LUHS, PPO and Non-PPO annual deductibles are not Combined)

LUHS

PPO

Non-PPO

Individual:

$300

$300

$300

Family:

2 individuals per family max

Out-of-Pocket Expense Limitation

The amount of money an individual contributes toward covered medical services during any one calendar year, including co-insurance payments.  Elective MSA co-payment, charges in excess of the Scheduled Maximum Allowance, Rx costs and deductibles do not apply to the out-of-pocket limitation. Separate Rx program Out-of-Pocket max – see Rx section below.

LUHS

PPO

Non-PPO

Individual:

$1,500

$1,500

$3,000

Family:

2 individuals out-of-pocket max

Hospital

LUHS

PPO

Non-PPO

Room allowance is based on the hospital’s most common semi-private room rate.  Pre-Admission Testing, Skilled Nursing Facilities, Hospice and Coordinated Home Health Care are also paid on the same basis.  Annual deductible does not apply.

100%

90%

75%

Per Inpatient Admission Deductible

MSA Non-Certification Deductible

$0

$0

$250

$100

$400

$100

Outpatient Hospital Surgery

Diagnostic Tests (annual deductible does not apply)

100%

90%

90%

80%

75%

70%

Outpatient Hospital Service

Includes radiation, chemotherapy, cardiac rehab, dialysis

100%

90%

75%

Hospital Emergency Medical/Accident Care

Initial treatment in hospital of accidental injuries or sudden and unexpected medical conditions with severe life-threatening symptoms.  If an inpatient admission occurs, MSA must be contacted within two business days or benefits will be reduced.  ER co-pay waived and inpatient deductible applies if admitted to hospital following ER care.

Emergency Room Co-pay:   $75 (annual deductible does not apply)

100%

100%

100%

Mental Health Services

Payment for Professional Services will be at Physician level based on Schedule of Maximum Allowances (SMA)

LUHS

PPO

Non-PPO

Chemical Dependency – Inpatient Inpatient Chem. Dep. - Physician (3 confinements or 60 days per lifetime)

Outpatient Chem. Dep. - Outpatient/Physician (52 visits/calendar year)

80%

[Outpatient - Not applicable at LUHS].  Provider services paid under the PPO or non-PPO level

80%

80%

80%

70%

70%

70%

Mental Health Services - Inpatient Inpatient Mental Health - Outpatient/Physician (3 confinements or 60 days per lifetime)

Outpatient Mental Health - Physician (52 visits/calendar year)

Mental Health and Chemical Dependency are not combined benefits.

80%

[Outpatient - Not applicable at LUHS]. Provider services paid under the PPO or non-PPO level

80%

80%

80%

70%

70%

70%

Based on Schedule of Maximum Allowances (SMA)

Staff Physician

PPO

Non-PPO

Physician Office Visits, X-ray and Lab

Co-Pay: NO

90%

80%

70%

Medical/Surgical Benefits or Inpatient/Outpatient Physician Services

Includes radiologist’s, anesthesiologist’s and surgeon’s charges

90%

80%

70%

Wellness Benefit: Immunizations, routine physical exam, routine diagnostic.  $750 calendar year maximum, per person. Annual deductible does not apply.

Co-Pay: NO

100%

100%

100%

Well Child Care Benefits: including physical exams, diagnostic tests and immunizations up to 24 months are paid at 100%, no deductible, no maximum. Immunizations at age 25 months and above are paid at 100% up to $750 per person wellness maximum.

Co-Pay: NO

100%

100%

100%

Chiropractic Services

90%

80%

70%

Physical, Speech, and Occupational Therapy

$3,000 calendar year maximum, per therapy

90%

80%

70%

• Ambulance
• Durable Medical Equipment and Prosthetics (Rental price covered up to the purchase price)
• Blood and blood components
• Leg, arm, and neck braces
• Private duty nursing—Limited to $1,000 per month
• TMJ* Lifetime Maximum $1,000
• Allergy shots
• Oxygen (includes administration)
• Surgical dressings
• Casts and splints

80%

Rx Program (Retail and Mail-Order)

$100 annual Rx Deductible (max 2 individuals per family)

90% Generic Rx

75% Brand Name Rx

Out-of-pocket maximum: $2,000 per person (max 2 individuals per family)

Infertility Treatment:

Medical Services Advisory

(MSA):

Notification required prior to all elective admissions.  Emergency and Obstetric Admission Notification required within 2 working days of admittance.  If employee elects not to notify MSA Advisor or follow advice given, hospital benefits will be reduced by $100.

Dependent Eligibility:

Covered to age 23 as an unmarried IRS dependent of the member’s plan.

Coordination of Benefits:

When you have health coverage through more than one group program, this program coordinates benefits with other group plans, based on the Birthday Rule.

Pre-Existing Conditions/Waiting Period:

None

For Provider Info:

Visit www.bcbsil.com