CITY OF CHAMPAIGN |
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PersonalCare HMO |
PersonalCare PPO |
Health Alliance HMO |
Health Alliance PPO |
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| Provider Selection | PersonalCare Providers Only | PersonalCare Providers Only | Any Licensed Provider | Health Alliance Providers Only | Health Alliance Providers Only | Any Licensed Provider |
| Lifetime Maximum | Unlimited | $2,000,000 (combined) | Unlimited | $2,000,000 (combined) | ||
| Deducatble | Not Applicable | $200-individual; $400-family | Not Applicable | $100-individual; $200-family | $200-individual; $400-family | |
| Not Applicable | Not Applicable | 10% | 20% | Not Applicable | 10% | 20% of UCR |
| Out-of-Pocket Maximum | $1000-individual; $3000-family | $500-individual; $1000-family | $1000-individual; $2000-family | $1500-individual; $3000-family | $500-individual; $1000-family | $1000-individual; $2000-family |
| PCP Office Visit | $10 copay | 10% | 20% | $10 copay | 10% | 20% of UCR |
| Specialist Office Visit | $10 copay | 10% | 20% | $10 copay | 10% | 20% of UCR |
| Xray & Lab | $0 copay | 10% | 20% | $0 copay | 10% | 20% of UCR |
| Child-Wellness Visits | $10 copay | 10% | 20%($150 cal yr. max) | $0 copay | 10% | 20% of UCR |
| Adult-Wellness Visits | $10 copay | 10% | 20%($150 cal yr max) | $0 copay | 10% | 20% of UCR |
| Emergency Room | $100 copay | 20% | 20% | $125 copay | 20% | 20% of UCR |
| Outpatient Surgery | $0 copay | 10% | 20% | $0 copay | 10% | 20% of UCR |
| Inpatient Hospitalization | $40 copay/day ($400 max/confinement) | 10% | 20% | $40 copay/day ($400 max/confinement) | 10% | 20% of UCR |
| Organ Transplants | 50% | 10% | 50% | Pay as with any other illness | 10% | 20% of UCR |
| Inpatient Mental/Nervous | $30 copay/day (14 days per year) | 10% (30 days per year) | 20% (30 days per year) | $50 copay/day (10 days per year) | 10% (30 days per year) | 20% of UCR (30 days per year) |
| Outpatient Mental/Nervous | $15 copay/day (20 visits per year) | 10% (20 visits per year) | 20% (20 visits per year) | $15 copay (20 visits per year) | 10% (20 visits per year) | 20% of UCR (20 visits per year) |
| Inpatient Substance Abuse | $30 copay/day (14 days per year) | 10% (30 days per year) | 20% (30 days per year) | $50 copay/day (10 days per year) | 10% (30 days per year) | 20% of UCR (30 days per year) |
| Outpatient Substance Abuse | $15 copay/day (20 visits per year) | 10% (20 visits per year) | 20% (20 visits per year) | $15 copay (20 visits per year) | 10% (20 visits per year) | 20% of UCR (20 visits per year) |
| Chiropractic Services | $10 copay | 30% ($500 combined max per year) | $15 copay | 10% ($500 combined max per year) | ||
| Skilled Nursing | $0 copay (120 days/year) | 10% (120 days/year) | 20% (120 days/year) | $0 copay (120 days/year) | 10% (120 days/year) | 20% of URC (120 days/year) |
| Durable Medical Equipment | 20% | 10% | 20% | 10% | 20% of URC | |
| Retail Prescription Drugs |
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| Generic | $7 copay | Not Covered | $7 copay | Not Covered | ||
| Brand (Formulary) | $15 copay | Not Covered | $15 copay | Not Covered | ||
| Brand (Non-Formulary) | $50 copay | Not Covered | $50 copay | Not Covered | ||
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