b'UnitedHealthcare Choice Plus PPO Blue Cross Blue ShieldHMO Illinois (HMOI)PROFESSIONAL AND OTHER SERVICES PROFESSIONAL AND OTHER SERVICESAllergy Shots Allergy ShotsNo charge$30 Office Visit CopayPhysician visit copay appliesAmbulance Ambulance80%PPO/Non-PPO after deductible No copayPrior authorization required for non-emergencyChiropractic VisitsChiropractic Visits $30 Copay80%PPO provider, after deductible Limited to 40 visits per year50%Non-PPO after deductibleLimited to 20 visits per year DentalAccidental care only: coverage provided for repair of Dental accidental injury to sound natural teeth80%PPO/Non-PPO after deductible Accident only; Prior authorization required Eyeglasses and ContactsEyeglasses and Contacts Covered up to $75 allowance every 24 monthsDiscounts on frames, lenses, and lens options. Contact EyeMed at 1-844-684-2254 for details on the vision discount program. MaternitySee applicable service for benefit level. Copay onlyMaternityapplies to initial office visit for physician office100% after $30 copayservices.Physician Office VisitsPhysician Office Visits $30Copay100% PPO provider, deductible does not apply $100Copay PPO specialist provider, deductible does Preventive Care Services (physicals, diagnosticnot apply tests, immunizations)50% Non-PPO provider after deductible No copayPreventive Care Services (physicals, diagnosticProsthetic Devices and Medical Equipmenttests, immunizations) No copay100% PPO for routine lab, x-rays, mammograms, Vision Screening and Examspreventive tests. PPO preventive care not $30Copaysubject to deductible50% Non-PPO after deductible Limited to one screening/exam every 12 monthsProsthetic Devices and Medical Equipment80% PPO after deductible 50% Non-PPO after deductibleLimited to single purchase of each type of device every 3 yearsVision Screening and ExamsNot coveredCTPF 2021 HEALTH INSURANCE HANDBOOKCTPF 2021 HEALTH INSURANCE HANDBOOK27'