Open Access Plan (OAP) Benefits

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The benefits described below represent the minimum level of coverage available in an OAP.  Benefits are in the plan's summary plan document.  It is the member's responsibility to know and follow the specific requirements outlined in the OAP plan.  The OAP provides three benefit levels broken into tier groups.  Tier I and Tier II require the use of network providers and offer benefits with pre-determined co-payments.  Tier III (out-of network) offers members flexibility in selecting health care providers with higher out-of-pocket costs.  Tier II and Tier III require deductibles.  It is important to remember the level of benefits is determined by the selection of care providers.  Members enrolled in the OAP can mix and match providers. 

HealthLink OAP Coventry OAP
1831 Chestnut Street
St Louis, MO 63103
(800) 624-2356
www.healthlink.com
Group Name: State of Illinois 
Group#: 160000 
Plan Code: 160000, 160001, 160002, 160003		 2110 Fox Drive
Champaign, IL 61820
800-431-1211
217-366-5551 TDD
chcillinois.coventryhealthcare.com


FY2015 OAP Plan Design
Benefits Tier I - 100% Benefit Tier II - 90% Benefit Tier III - Out-of-Network 60% Benefit
Plan Year Maximum Benefit Unlimited Unlimited Unlimited
Lifetime Maximum Unlimited Unlimited Unlimited
Annual Out-of Pocket Max Per Individual Enrollee Per Family $6,250 (includes eligible charges from Tier 1 and 2 combined)
$12,700		 Not Applicable Not Applicable
Annual Plan Deductible (must be satisfied for all services) Not Applicable $250 per enrollee $350 per enrollee


FY2015 Hospital Services
Inpatient 100% after $350 co-payment per admission 90% of network charges after the annual plan deductible and a $400 copayment per admission 60% of U&C after the annual plan deductible and a $500 copayment per admission
Inpatient Psychiatric 100% after $350 co-payment per admission 90% of network charges after the annual plan deductible and a $400 copayment per admission 60% of U&C after the annual plan deductible and a $500 copayment per admission

Inpatient Alcohol and Substance Abuse
100% after $350 co-payment per admission		 90% of network charges after the annual plan deductible and a $400 copayment per admission 60% of U&C after the annual plan deductible and a $500 copayment per admission
Emergency Room 100% after $250 co-payment per visit 100% after the annual plan deductible and a $250 copayment per visit 100% after the annual plan deductible and a $250 copayment per visit
Outpatient Surgery 100% after $250 co-payment per visit 90% of network charges after the annual plan deductible and a $250 copayment 60% of U&C after the annual plan deductible and a $250 copayment
Diagnostic Test & Imaging 100% 90% of network charges after the annual plan deductible 60% of U&C after the annual plan deductible


FY2015 Physician and Other Professional Services
Physician Office Visits 100% after $20
co-payment		 90% for network charges after the annual plan deductible 60% of U&C after the annual plan deductible
Speciality Office Visits 100% after $30
co-payment		 90% of network charges after the annual plan deductible 60% of U&C after the annual plan deductible
Preventative Services Including Immuizations, alergy testing & treatment 100% 100% Covered in Tier I and Tier II only
Well Baby Care (first year life) 100% 100% Covered in Tier I and Tier II only
Outpatient Psychiatric & Substance Abuse 100% after $20 or $30
co-payment		 90% of network charges 60% of U&C


FY2015 Other Services
Durable Medical Equipment 80% of network charges 80% of network charges 60% of Allowable Charges
Skilled Nursing Facility 100% 90% of network charges Covered in Tier I and Tier II only
Transplant Coverage 100% 90% of network charges Covered in Tier I and Tier II only
Home Health Care 100% after $30 co-payment 90% of network charges Covered in Tier I and Tier II only


FY2015 Prescription Drugs
Prescription Drug Deductible $100 Per Individual
Prescription Drug Copay

30 Day Supply:
$8 copay for Generic
$26 copay for Preferred Brand
$50 copay for Non-Preferred Brand


FY2014 OAP Plan Design
Benefits Tier I - 100% Benefit Tier II - 90% Benefit Tier III - Out-of-Network 80% Benefit
Plan Year Maximum Benefit Unlimited Unlimited Unlimited
Lifetime Maximum Unlimited Unlimited Unlimited
Annual Out-of Pocket Max Per Individual Enrollee Per Family Not Applicable $900 

$1,500		 $1,800

$3,800
Annual Plan Deductible (must be satisfied for all services) Not Applicable $250 per enrollee $350 per enrollee


FY2014 Hospital Services
Inpatient 100% after $325 co-payment per admission 90% of network charges after the annual plan deductible and a $375 copayment per admiss7on 60% of allowable charges after $475 copayment per admission
Inpatient Psychiatric 100% after $325 co-payment per admission 90% of network charges after the annual plan deductible and a $375 copayment per admission 60% of allowable changes after $475 copayment per admission

Inpatient Alcohol and Substance Abuse
100% after $325 co-payment per admission		 90% of network charges after the annual plan deductible and a $375 copayment per admission 60% of allowable charges after $475 copayment per admission
Emergency Room 100% after $225 co-payment per visit 100% after the annual plan deductible and a $225 copayment per visit 100% after $225 copayment per visit
Outpatient Surgery 100% after $225 co-payment per visit 90% of network charges after the annual plan deductible and a $225 copayment 60% of allowable charges after $225 copayment
Diagnostic Test & Imaging 100% 90% of network charges after the annual plan deductible 60% of allowable charges


FY2014 Physician and Other Professional Services
Physician Office Visits 100% after $18 
copayment		 90% for network charges 60% of allowable charges
Speciality Office Visits 100% after $25 
copayment		 90% of network charges 60% of allowable charages
Preventative Services Including Immuizations, alergy testing & treatment 100% 100% Covered in Tier I and Tier II only
Well Baby Care (first year life) 100% 100% Covered in Tier I and Tier II only
Outpatient Psychiatric & Substance Abuse 100% after $18 or 25
copayment		 90% of network charges 60% of allowable charges


FY2014 Other Services
Durable Medical Equipment 80% of network charges 80% of network charges 60% of U&C
Skilled Nursing Facility 100% 90% of network charges Covered in Tier I and Tier II only
Transplant Coverage 100% 90% of network charges Covered in Tier I and Tier II only
Home Health Care 100% after $25 co-payment 90% of network charges Covered in Tier I and Tier II only


FY2014 Prescription Drugs
Prescription Deductible $75 Per Individual
Prescription Drug Copay

30 Day Supply:
$8 for Generic
$26 for Preferred Brand
$50 for Non-Preferred Brand

*Annual plan deductible must be met before benefits apply. Benefit limits are measured on a plan year. Plan co-payments deductibles and amounts over usual & customary (U & C) do not count toward the out-of-pocket maximum.