Local Government Health Plan (LGHP)

Plan Year 2020 Highlights (effective July 1, 2019 - June 30, 2020)

2020 Plan Documents | 2020 Summary of Benefits and Coverage | HMO Policy | State of Illinois Employees Open Enrollment Guide| Specialty Drug List

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Plan Year Deductible

$0
$175 for prescriptions

Plan Year Out-of-Pocket Maximum

$3,000 per individual
$6,000 per family

Copayment, coinsurance, and deductible payments for the services listed below apply to the plan year out-of-pocket maximum.

Medical Benefits

  $ = Copay         % = Coinsurance  

Physician Visit $40
Specialist $45
Wellness and Preventive Services
Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0
Emergency Room $300
Ambulance Transport $0
Urgent Care $40
Diagnostic Testing - X-Rays, Lab Services
Preauthorization is required for imaging.
$0
Outpatient Surgery
Preauthorization may be required for certain procedures.
$300
Hospitalization
Preauthorization is required.
$350
Home Health Care
Preauthorization is required.
$45
Rehabilitation Services
Preauthorization is required. Up to 60 visits per condition per plan year.
$40
Skilled Nursing Care
Preauthorization is required.
$0
Durable Medical Equipment
Preauthorization may be required for certain medical equipment.
30%
Hospice Services $0
 

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Prescription Drugs

Generic
30-day supply
90-day supply
$15
$37.50
Preferred Brand
30-day supply
90-day supply
$30
$75
Non-Preferred Brand
30-day supply
90-day supply
$60
$150
 

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Maternity

Prenatal Care $50 per pregnancy
Maternity Inpatient $350
 

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Mental Health

Mental Health, Behavioral Health, or Substance Abuse Services - Outpatient $40
Mental Health, Behavioral Health, or Substance Abuse Services - Inpatient
Preauthorization is required.
$350
 

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