Teachers' Retirement Insurance Program (TRIP)

Plan Year 2019 Highlights (effective July 1, 2018, to June 30, 2019)

2019 Plan Documents | 2019 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

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 $30
Specialist $30
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 $200
Ambulance Transport $0
Urgent Care $30
Diagnostic Testing - X-Rays, Lab Services
Preauthorization is required for imaging.
$0
Outpatient Surgery
Preauthorization may be required for certain procedures.
$200
Hospitalization
Preauthorization is required.
$250
Home Health Care
Preauthorization is required.
$15
Rehabilitation Services
Preauthorization is required. Up to 60 visits per condition per plan year.
$30
Skilled Nursing Care
Preauthorization is required.
$0
Durable Medical Equipment
Preauthorization may be required for certain medical equipment.
20%
Hospice Services $0
 

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Prescription Drugs

Generic
30-day supply
90-day supply
$10
$25
Preferred Brand
30-day supply
90-day supply
$24
$60
Non-Preferred Brand
30-day supply
90-day supply
$48
$120
 

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Maternity

Prenatal Care $50 per pregnancy
Maternity Inpatient $250
 

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Mental Health

Mental Health, Behavioral Health, or Substance Abuse Services - Outpatient $30
Mental Health, Behavioral Health, or Substance Abuse Services - Inpatient
Preauthorization is required.
$250
 

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