BCBS Preferred PPO

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BCBS Preferred PPO

Northrop Grumman Corporation2008 Retiree Plan BenefitsFeatureBCBS Preferred PPO - Pre-65In-NetworkOut-of-NetworkProviderBlueCross BlueShield of Illinois1-800-516-1269www.bcbsil.comCost SharingAnnual Deductible $500 Individual; $1,000 Family $800 Individual; $1,600 FamilyOut-of-pocket maximum $3,000 Individual; $6,000 Family $5,000 Individual; $10,000 FamilyLifetime coverage limit$2,000,000; for all Northrop Grumman-sponsored medical plan options; retireeand active combined; in and out-of-network combinedPolicies/RequirementsNeed to file claims No YesDomestic partner benefits Yes YesAccessAbility to self-refer to OB/GYN Yes YesAbility to self-refer to specialists Yes YesOut-of-area dependent coverage Yes YesOut-of-area participant coverage Yes YesSpending AccountHRA -- You only Not applicable Not applicableHRA -- You and spouse Not applicable Not applicableHRA -- You and child Not applicable Not applicableHRA -- You and family Not applicable Not applicableEligible expenses forNot applicableNot applicablereimbursementOutpatient ServicesPrimary doctor office visit $20 copay 60% covered after deductible is metSpecialist doctor office visit $40 copay 60% covered after deductible is metPreventive CareAnnual physical exam$20 copay; PCP; $40 copay specialist;services must meet prescribeddefinition of preventive servicesNot coveredWell-woman exam (includes pap)MammogramPediatric examsImmunizations (child)$20 copay; PCP; $40 copay specialist;services must meet prescribeddefinition of preventive services100% covered; services must meetprescribed definition of preventiveservices$20 copay; PCP; $40 copay specialist;services must meet prescribeddefinition of preventive services100% covered; coverage based onAmerican Academy of Pediatricsguidelines; services must meetprescribed definition of preventiveservicesNot coveredNot coveredNot coveredNot coveredPage 1 of 5


Northrop Grumman Corporation2008 Retiree Plan BenefitsFeatureIn-NetworkColorectal screening 100% covered; physician charges; 90%covered after ded is met for facilitycharges; services must meetprescribed definition of preventiveservicesCancer screeningsCardiovascular screenings100% covered; services must meetprescribed definition of preventiveservices100% covered; services must meetprescribed definition of preventiveservicesBCBS Preferred PPO - Pre-65Out-of-Network100% covered; physician charges; 60%covered after ded is met for facilitycharges; services must meetprescribed definition of preventiveservicesNot coveredNot coveredAllergy tests and treatments 90% covered after deductible is met 60% covered after deductible is metOutpatient CareOutpatient surgery 90% covered after deductible is met 60% covered after deductible is metOutpatient laboratory services 90% covered after deductible is met 60% covered after deductible is metOutpatient physical therapy 90% covered after deductible; limited to 60% covered after deductible; limited to50 visits per benefit plan year; in- andout-of-network combined50 visits per benefit plan year; in- andout-of-network combinedOutpatient X-ray 90% covered after deductible is met 60% covered after deductible is metOutpatient occupational therapy 90% covered after deductible is met; 60% covered after deductible is met;limited to 50 visits per benefit plan year; limited to 50 visits per benefit plan year;in and out-of-network combined in and out-of-network combinedOutpatient speech therapyOutpatient cardiac rehabilitation90% covered after deductible is met;limited to 50 visits per benefit plan year;in and out-of-network combined90% covered after deductible is met;limited to Phase 1 and Phase 2 care60% covered after deductible is met;limited to 50 visits per benefit plan year;in and out-of-network combined60% covered after deductible is met;limited to Phase 1 and Phase 2 careFamily Planning / Maternity CareOffice visit: pre/postnatal $20 copay 60% covered after deductible is metIn-hospital delivery services 90% covered after deductible is met 60% covered after deductible is metNewborn nursery services 90% covered after deductible is met 60% covered after deductible is metFertility services90% covered after deductible is met;limited to $25,000 per lifetime; in andout-of-network combined60% covered after deductible is met;limited to $25,000 per lifetime; in andout-of-network combinedIn vitro fertilization90% covered after deductible is met;limited to $25,000 per lifetime for all60% covered after deductible is met;limited to $25,000 per lifetime for allfertility services combined; in and out-of-fertilitnetwork services combined; in and out-of-combinednetwork combinedArtificial insemination90% covered after deductible is met;limited to $25,000 per lifetime for all60% covered after deductible is met;limited to $25,000 per lifetime for allfertility services combined; in and out-of-fertilitnetwork services combined; in and out-of-combinednetwork combinedFemale tubal ligation 90% covered after deductible is met 60% covered after deductible is metMale vasectomy 90% covered after deductible is met 60% covered after deductible is metPage 2 of 5


Northrop Grumman Corporation2008 Retiree Plan BenefitsFeatureBCBS Preferred PPO - Pre-65In-NetworkOut-of-NetworkHearingHearing evaluations100% covered; limited to one exam per 100% covered; limited to one exam perbenefit plan yearbenefit plan yearHearing aidsLimited to $500 per ear per benefit plan Limited to $500 per ear per benefit planyear including exam, hearing aids (one year including exam, hearing aids (onehearing aid per ear every three years),and hearing aid repairhearing aid per ear every three years),and hearing aid repairVisionRoutine vision exams Not covered Not coveredRegular lenses and frames Not covered Not coveredContact lenses Not covered Not coveredDentalDental implants Not covered Not coveredAccidental injury to teeth 90% covered after deductible is met 60% covered after deductible is metSurgical removal of tumors, cysts 90% covered after deductible is met 60% covered after deductible is metand impacted teethInpatient ServicesHospital copay90% covered; after deductible is met; 60% covered after deductible is metpreauthorization requiredHospital semi-private room 90% covered after plan deductible; 60% covered after plan deductiblepreauthorization requiredInpatient lab and X-ray90% covered; after deductible is met; 60% covered after deductible is metpreauthorization requiredInpatient surgery90% covered after deductible; 60% covered after deductible is metpreauthorization requiredInpatient physician and surgeonservices90% covered; after deductible is met;preauthorization required60% covered; after deductible is metEmergency Care90% covered after deductible is met;plus $100 deductible for nonemergencies90% covered after deductible is met;true emergency; 60% covered afterdeductible is met plus $100 deductiblefor non-emergenciesUrgent care clinic visit 90% covered after deductible is met 60% covered after deductible is metEmergency room (not followed byadmission)Ambulance services90% covered after deductible is met; in and out-of network; non-emergenciesnot coveredPrescription Drug Coverage: see Express Scripts summaryAnnual prescription deductible Not applicable Not applicablePrescription drug website Not applicable Not applicablePrescription drug member services Not applicableNot applicablePrescription drug vendor Not applicable Not applicableAnnual Rx out-of-pocket maximum Not applicableNot applicableRetailRetail generic Not applicable Not applicableRetail formulary brand Not applicable Not applicableRetail nonformulary brand Not applicable Not applicablePage 3 of 5


Northrop Grumman Corporation2008 Retiree Plan BenefitsFeatureIn-NetworkBCBS Preferred PPO - Pre-65Out-of-NetworkMail OrderMail order generic Not applicable Not applicableMail order formulary brand Not applicable Not applicableMail order nonformulary brand Not applicable Not applicableOtherOral contraceptives Not applicable Not applicableFertility drugs Not applicable Not applicableRetail injectable drugs Not applicable Not applicableMental HealthMental Health: Combined with YesYessubstance abuseMental Health: Outpatient coverage $15 copay60% covered; limited to 30 visits perbenefit plan yearMental Health: Inpatient coverage 90% covered 60% covered; limited to 30 days perbenefit plan yearDetox: Outpatient coverageDetox: Inpatient coverageSubstance Abuse90% covered; limited to 3 courses oftreatment per lifetime; in and out-ofnetworkcombined90% covered; limited to 3 courses oftreatment per lifetime; in and out-ofnetworkcombined60% covered; limited to 30 days perbenefit plan year; limited to 3 coursesof treatment per lifetime; in and out-ofnetworkcombined60% covered; limited to 30 days perbenefit plan year; limited to 3 coursesof treatment per lifetime; in and out-ofnetworkcombinedRehab: Outpatient coverage $15 copay 60% covered; limited to 30 visits perbenefit plan yearRehab: Inpatient coverage 90% covered; limited to 3 courses oftreatment per lifetime; in and out-ofnetworkcombinedChiropracticAcupunctureHeart disease care managementHypertension care managementDiabetes care managementAsthma care managementPrenatal care managementCancer care managementSmoking cessation programWeight control program60% covered; limited to 30 days perbenefit plan year; limited to 3 coursesof treatment per lifetime; in and out-ofnetworkcombinedAlternative Care$40 copay; 90% covered after 60% covered after deductible is met;deductible is met if no office visit billed; limited to 40 visits per benefit plan year;limited to 40 visits per benefit plan year; in and out-of-network combinedin and out-of-network combined90% covered after deductible is met; 60% covered after deductible is met;limited to 20 visits per benefit plan year; limited to 20 visits per benefit plan year;in and out-of-network combined in and out-of-network combinedCare Management ProgramsYes; offered through CareWiseYes; offered through CareWiseYes; offered through CareWiseYes; offered through CareWiseYes; offered through CareWiseYes; offered through CareWiseNoNoPage 4 of 5


Northrop Grumman Corporation2008 Retiree Plan BenefitsFeatureIn-NetworkBCBS Preferred PPO - Pre-65Out-of-NetworkOtherNoncustodial home health care 90% covered after deductible is met;limited to 120 visits per benefit planyear; in and out-of-network combined;preauthorization required60% covered after deductible is met;limited to 120 visits per benefit planyear; in and out-of-network combined;preauthorization requiredHospice care 90% covered after deductible is met 60% covered after deductible is metPrescribed care in noncustodialskilled nursing facility90% covered after deductible is met;limited to 120 days per benefit planyear; in and out-of-network combined;preauthorization required60% covered after deductible is met;limited to 120 days per benefit planyear; in and out-of-network combined;preauthorization requiredDurable medical equipment 90% covered after deductible is met 60% covered after deductible is metProsthetic devices 90% covered after deductible is met 60% covered after deductible is metPage 5 of 5

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