PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

Type of Services In-Network Out-of-Network
Hospital and Surgery Centers
Inpatient care2,3 Outpatient surgery2 Outpatient non-surgical care2 Emergency Room
Facility charges2 Physician charges
Physician Services
Pediatric care
Office visit for treatment of
illness or injury
Diagnostic lab test and x-rays
In-office allergy treatment and
materials
Casts, splints, crutches, braces
and prosthetic devices
Hearing and vision exams due to
illness or injury
Outpatient surgery
Infertility
Inpatient care
After you pay the deductible, Plan pays
80% of covered expenses
After you pay the deductible
and a $200 copayment per visit
(copayment waived if admitted to
hospital), Plan pays 80% of covered
expenses
After you pay the deductible,
Plan pays 80% of covered expenses
After you pay the deductible, Plan pays
80% of covered expenses
After you pay the deductible, Plan pays
60% of reasonable and customary
charges
After you pay the deductible
and a $200 copayment per visit
(copayment waived if admitted
to hospital), Plan pays 80% of
reasonable and customary charges
After you pay the deductible and a
$200 copayment per visit, Plan pays
60% of reasonable and customary
charges (if treatment is for a nonemergency)
After you pay the deductible,
the Plan pays 80% of reasonable and
customary charges
After you pay the deductible,
the Plan pays 60% of reasonable and
customary charges (if treatment is
for a non-emergency)
After you pay the deductible, Plan pays
60% of reasonable and customary
charges
$50,000 lifetime maximum benefit
2 When you receive services from an Advocate facility—Advocate will waive 10% of your portion of the coinsurance amount; you will be
responsible for 10%. You must still satisfy the annual deductible before benefits begin—except for preventive care.
3 Care must be pre-certified; the number to call to initiate the pre-certification process is on the back of your coverage ID card.
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