b'UnitedHealthcare Choice Plus PPO Blue Cross Blue ShieldHMO Illinois (HMOI)ANNUAL MEDICAL PLAN YEAR DEDUCTIBLE ANNUAL MEDICAL PLAN YEAR DEDUCTIBLEIndividual: $2,000PPO None$5,000Non-PPOFamily:$4,000PPO ADDITIONAL DEDUCTIBLES$10,000Non-PPO NoneDeductible does not apply to all services. HOSPITAL SERVICESADDITIONAL DEDUCTIBLESEmergency Room Inpatient$250 per occurrence deductible $200Copay per admissionHOSPITAL SERVICES (not to exceed 2 copays per year)Inpatient Skilled Nursing Facility (non-custodial)80% PPO after deductible50% Non-PPO after deductible, priorNo copayauthorization requiredOUTPATIENT SERVICESSkilled Nursing Facility (non-custodial)80%PPO after deductible Chemotherapy, Radiation Therapy50%Non-PPO after deductible $30CopayLimited to 60 days per yearOUTPATIENT SERVICES Emergency Room$125Copay: PCP notification recommended except Chemotherapy, Radiation Therapyin life threatening situation80%PPO after deductible50%Non-PPO after deductible Lab/X-rayEmergency Room $30Copay80% after a $250 per occurrence deductible per visit and the medical plan deductible has been met (PPOSpeech, Physical and Occupational Therapyand non-PPO) No copayLab/X-ray Limited to 60 visits per year80%PPO provider, after deductible50%Non-PPO provider, after deductible SurgerySpeech, Physical and Occupational Therapy $175Copay80% PPO provider, after deductible50%Non-PPO provider, after deductible Urgent CareNo limit to speech or occupational therapy. Limited to$30Copay60 visits per year per calendar year for pysical therapy for Multiple Sclerosis Surgery80%PPO after deductible50%Non-PPO after deductibleUrgent Care$50 Copay PPO, deductible does not apply50%Non-PPO, after deductible14 CTPF 2024 NON-MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2024 NON-MEDICARE HEALTH INSURANCE HANDBOOK'