Medical and Prescription Drug Benefits
The American Lung Association offers three medical plan options: administered by BCBSIL. All of the medical options include coverage for prescription drugs.
Eligible employees can choose among three plan options:
- $500 Deductible PPO
- $1,500 Deductible PPO
- $3,500 Deductible HDHP with Health Savings Account (HSA)
The PPO plans require copays for doctor visits and prescriptions, individual deductibles and 20% coinsurance for larger services such as hospital stays and imaging tests.
The HDHP with HSA plan requires the entire individual deductible to be met before the plan begins to pay. This is also the only plan that allows you to contribute toward an HSA on a pre-tax basis.
Understanding how your plan works
Copays
Depending on which plan you choose, you’ll pay a copay for specific expenses. The copay may be in addition to your deductible for some expenses.
Deductible
You’ll pay out-of-pocket for certain medical and prescription drug expenses until you reach the deductible.
Coinsurance
Once your deductible is met, you and the plan share the cost of covered expenses with coinsurance. The plan will pay a percentage of each eligible expense, and you will pay the rest.
Out-of-Pocket Maximum
When you reach your out-of-pocket maximum, the plan pays 100% of covered expenses for the rest of the plan year. Your deductible and coinsurance apply toward the out-of-pocket maximum.
To select the plan that best suits your family, you should consider the key differences between the plan, the cost of coverage (including payroll deductions) and how the plan covers services throughout the year.
Compare medical coverage
Preventive care
This includes an annual physical exam, lab work and routine immunizations, screenings and other services intended to prevent illness or detect problems before you notice any symptoms. All three medical plans cover in-network preventive care at 100% (no cost to you).
Deductibles and out-of-pocket maximums
- The $500 Deductible PPO and the $1,500 Deductible PPO feature embedded deductibles and out-of-pocket maximums. This means each person only needs to meet the individual deductible and out-of-pocket maximum before the plan begins paying its share for that individual. Once three or more family members meet the family limits, the plan begins paying its share for all covered family members.
- The $3,500 Deductible HDHP with HSA has a true family deductible where the overall family deductible must be met before the plan begins to pay.
Tax advantaged accounts
Depending on which plan you enroll in, you can contribute toward either a Health Savings Account (HSA) or Health Care Flexible Spending Account (FSA) on a pre-tax basis to help pay for eligible medical, dental, vision, and prescription drug expenses. Visit Tax Advantaged Accounts to learn more.
| Plan Provisions | $500 DEDUCTIBLE PPO | $1,500 DEDUCTIBLE PPO | PPO $3,500 DEDUCTIBLE HDHP W/HSA |
|---|---|---|---|
| In-Network | In-Network | In-Network | |
| Annual Deductible (Individual/Family) | $500/$1,500 | $1,500/$4,500 | $3,500/$7,000 |
| Out-of-Pocket Maximum (Includes Deductible) | $2,500/$7,500 | $3,500/$10,500 | $5,800/$7,350 |
| Preventive Care | No charge | No charge | No charge |
| Primary Care Provider Office Visit | $20 copay | $30 copay | Deductible + coinsurance |
| Specialist Office Visit | $40 copay | $50 copay | Deductible + coinsurance |
| X-Ray and Lab | $20 copay PCP $40 copay specialist |
$30 copay PCP $50 copay specialist |
Deductible + coinsurance |
| Inpatient Hospital Services | Deductible + coinsurance | Deductible + coinsurance | Deductible + coinsurance |
| Outpatient Hospital Services | Deductible + coinsurance | Deductible + coinsurance | Deductible + coinsurance |
| Urgent Care | Deductible + coinsurance | Deductible + coinsurance | Deductible + coinsurance |
| Emergency Room | $150 copay | $150 copay | Deductible + coinsurance |
Compare prescription drug coverage
Preventive drugs
These are covered at 100% (no cost to you) if you use a preferred pharmacy. Refer to the PPACA $0 Cost-share Preventive Medication List to see which medications are considered preventive.
Drug tiers
Medications may be generic, brand, or specialty, and within each of those categories, may be preferred or non-preferred. Preferred drugs are usually less expensive than other options. Prescriptions may also be less expensive if filled at an in-network pharmacy.
- Generic: A drug that offers equivalent uses, doses, strength, quality and performance as a brand-name drug, but is not trademarked.
- Brand: A drug with a patent and trademark name that is usually more expensive than alternative generic options.
- Specialty: A drug that requires special handling, administration or monitoring. Most can only be filled by a specialty pharmacy and have additional required approvals.
These tiers also affect your coverage, so review the Prescription Drug List (PDL) carefully (expand Prescription Drug Lists for Employer-offered Plans: Large Group (51 or more) and select the Performance Drug List).
Mail-order Pharmacy
If you take a maintenance medication on an ongoing basis for a condition like high cholesterol or high blood pressure, you can use the mail-order pharmacy to obtain a 90-day supply of your medication.
| Retail Pharmacy (up to a 30-day supply) | $500 DEDUCTIBLE PPO | $1,500 DEDUCTIBLE PPO | PPO $3,500 DEDUCTIBLE HDHP W/HSA |
|---|---|---|---|
| Preferred Generic | Preferred pharmacy: $0 Non-preferred pharmacy: $10 | Preferred pharmacy: $0 Non-preferred pharmacy: $10 | Deductible, then Preferred pharmacy: 10% Non-preferred pharmacy: 20% |
| Non-preferred Generic | Preferred pharmacy: $10 Non-preferred pharmacy: $20 |
Preferred pharmacy: $10 Non-preferred pharmacy: $20 |
Deductible, then Preferred pharmacy: 10% Non-preferred pharmacy: 20% |
| Preferred Brand | Preferred pharmacy: $50 Non-preferred pharmacy: $70 | Preferred pharmacy: $50 Non-preferred pharmacy: $70 | Deductible, then Preferred pharmacy: 20% Non-preferred pharmacy: 30% |
| Non-preferred Brand Name | Preferred pharmacy: $100 Non-preferred pharmacy: $120 | Preferred pharmacy: $100 Non-preferred pharmacy: $120 | Deductible, then Preferred pharmacy: 30% Non-preferred pharmacy: 40% |
| Preferred Specialty | $150 | $150 | Deductible, then 40% |
| Non-preferred Specialty | $250 | $250 | Deductible, then 50% |
Manage your medical care
When you enroll in a BCBSIL medical plan, you have access to many additional resources that can support your total wellbeing, such as:
- Virtual and in-person primary and preventive care
- Diabetes, hypertension and weight management
- Mental health and mindfulness programs
- Virtual physical therapy
- Fitness and nutrition
Visit Manage Your Medical Care for details.