$5.0 million Lifetime Maximum
Six-month preexisting condition limitation for all
services, drugs and supplies for the Traditional and
Medicare Plans; but not for the HIPAA Plans.
For the standard calendar-year deductible plans:
$500, $1,000, $1,500, $2,500 and $5,000.
For the High Deductible Health Plans: $1,200,
$2,000 and $5,200.
Coinsurance for allowable charges: 20% in network
and 40% if non-PPO providers are used.
No deductible for the Traditional and HIPAA
standard calendar-year deductible plans.
Deductible must be met before any benefits are
payable for the High Deductible Health Plans.
No Prescription drug coverage for the Medicare
Calendar year Out-of-Pocket limits:
In-network: $1,500 coinsurance plus the appli-cable
deductible for the standard calendar year
deductible plans. For High Deductible Plans:
$2,700 for the $1,200 deductible plan ($1,200
deductible plus $1,500 coinsurance); $4,500 for
the $2,000 deductible plan ($2,000 deductible
plus $2,500 coinsurance); and $5,200 for the
$5,200 deductible plan.
Out-of-network: An additional $4,500 coinsur-ance
limit applies to the standard plans if non-
PPO providers are used. An additional $6,000
coinsurance limit applies to the High Deducti-ble
Health Plans if non-PPO providers are
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Phone Toll Free: 866-851-2751
Illinois Comprehensive Health Insurance Plan
320 West Washington Street Suite 700
Springfield, Illinois 62701-1150
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