b'Blue Cross Blue Shield PPO Blue Cross Blue ShieldHMO Illinois (HMOI)ANNUAL MEDICAL PLAN YEAR DEDUCTIBLE ANNUAL MEDICAL PLAN YEAR DEDUCTIBLE$1,500 PPO (in network) None$3,000 Non-PPO (out of network)ADDITIONAL DEDUCTIBLES ADDITIONAL DEDUCTIBLES$0 Deductible each PPO hospital admission None$0 Deductible each non-PPO hospital admissionHOSPITAL SERVICESHOSPITAL SERVICESInpatient Inpatient90%PPO hospital $200Copay per admission50%Non-PPO hospital (not to exceed 2 copays per year)Skilled Nursing Facility (non-custodial) Skilled Nursing Facility (non-custodial)90%PPO facility No copay50%Non-PPO facilityServices must be rendered in a OUTPATIENT SERVICESBCBS-approved skilled nursing facility.OUTPATIENT SERVICES Chemotherapy, Radiation Therapy$30CopayChemotherapy, Radiation Therapy90% PPO providerEmergency Room50% Non-PPO provider $125Copay: PCP notification recommended except Emergency Roomin life threatening situation80% After $200 emergency room deductible, unless admitted Lab/X-rayLab/X-ray $30Copay90% PPO provider 50% Non-PPO provider Speech, Physical and Occupational TherapySpeech, Physical and Occupational Therapy No copay90%PPO providerLimited to 60 visits per year50%Non-PPO providerSurgery Surgery90% PPO provider $175Copay50% Non-PPO provider Urgent CareUrgent Care $30Copay$50Copay PPO provider50% Non-PPO providerCTPF 2025 NON-MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2025 NON-MEDICARE HEALTH INSURANCE HANDBOOK 13'