Southern Illinois Health & Welfare Insurance Trust
Click the links below for Plan B Complete Schedule of Benefits and Enrollment Forms.
SIHWIT PLAN B SCHEDULE OF BENEFITS
DEDUCTIBLE/OUT-OF-POCKET/PENALTIES |
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SUMMARY OF SERVICES |
NETWORK PROVIDERS |
NON-NETWORK PROVIDERS |
Mandatory Hospital Pre-Admission and Outpatient Services Review Refer To The Section Entitled “Utilization Review Program” |
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Non-Compliance Penalty |
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Inpatient Services (Medical, Surgical, Behavioral) |
25% up to $1,000 |
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Surgical Procedures (Ambulatory) |
25% up to $1,000 |
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Ancillary Services |
25% up to $1,000 |
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Durable Medical Equipment |
25% up to $1,000 |
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Diagnostic Imaging (Ambulatory) |
25% up to $1,000 |
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Annual Maximum Benefit |
Unlimited |
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Lifetime Maximum Benefit |
Unlimited |
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Calendar Year Deductible |
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Individual |
$5,000 |
$10,000 |
Family |
$10,000 |
$20,000 |
Note: The Family Deductible Maximum includes covered expenses which are used to satisfy Deductibles for all family members combined. |
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Network Providers, and Non-Network Providers expenses will be applied equally toward the satisfaction of the Network Providers, and Non-Network Providers Deductible amounts. |
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Out-of-Pocket Maximum (including Deductible, Medical Co-payments, Prescription Drug Co-payments and Medical Co-insurance) |
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Individual |
$6,350 |
$12,800 |
Family |
$12,700 |
$25,600 |
Note: The Family Out-of-Pocket Maximum includes Out-of-Pocket expenses for all family members combined. |
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Network Providers and Non-Network Providers expenses will be applied equally toward the satisfaction of the Network Providers and Non-Network Providers Out- of-Pocket Maximums. |
Click to Download Complete Schedule of Benefits
SIHWIT Plan B 9-1-16
Southern Illinois Health Wellness Insurance Trust Plan B 9-1-16 PD-SPD
