Emergency Room Copay. For each emergency room visit, you pay a $250 Copay regardless of whether you receive services from In-Network or Out-of-Network Providers. If you are admitted directly to the Hospital as an inpatient from the emergency room within 24 hours, the Emergency Room Copay will be waived and the services you receive will be subject to Deductible and Co-insurance.
Emergency Room Copay. Waived if admitted. $150 copay $150 copay†† $150 copay $150 copay Inpatient Hospital Services 100% 100% 80% 100% Outpatient Hospital Services 100% 100% 80% 100% (deductible waived) Outpatient Surgery & Diagnostics 100% 100% 80% 100% (deductible waived) Medical / Surgical Services 100% 100% 80% 90% PRESCRIPTION DRUGS Retail Copayments are for up to a 34-day supply at a contracting retail pharmacy. $10 / $15 / $25 †† $0 / $20 / $40 $10 / $30 / $50 $10 / $15 / $25 Mail Service Maintenance medications are available for up to a 90-day supply. $10 / $15 / $25 †† $0 / $20 / $40 $20 / $60 / $100 $10 / $15 / $25 ADDITIONAL SERVICES Muscle Manipulation Services 100% (Max 60 visits) 100% (Max 25 visits) $40 copay (Max 25 visits) 90% Therapy Services – Speech, Occupational and Physical • Limited to 60 visits per therapy per calendar year. MY BENEFIT COST Monthly Amount You Pay with Wellness Incentive† • You Only 100% 100% 80% 90% $35.00 $20.00 $70.00 $190.00 • You + Spouse $75.00 $35.00 $145.00 $366.00 • You + Kid(s) $70.00 $30.00 $140.00 $350.00 • Family $125.00 $40.00 $210.00 $550.00 Contact us * Out-of-network coverage information is detailed in the Certificates of Health Care Benefits prepared by BCBS. Available at xxx.xxXXxxxXxxxxxxxx.xxx. ** Embedded Family Deductible Feature (HDHP/HSA Plan): If an individual who has family coverage satisfies the individual deductible, their in-network benefits will be covered at 100%. *** Does not apply to benefit continuation participants or officials. **** Does not include amounts over the Schedule of Maximum Allowances (SMA). † Assumes employee participation in wellness incentive. Refer to the myWellness factsheet for additional monthly cost without participation in the wellness incentive. †† Deductible must be met, then copay applies. Human Resources Office 708.403.6155 wellness consumerism choice VILLAGE OF ORLAND PARK BENEFITS PROGRAM This publication represents a brief summary of the medical plans offered by the Village of Orland Park. The individual Certificates of Health Care Benefits prepared by BCBS are the official documentation of each specific plan. The Certificates will govern over this summary should there be a discrepancy. my Plan Comparison VILLAGE OF ORLAND PARK BENEFITS PROGRAM EFFECTIVE JANUARY 1, 2016 / MAP factsheet APPENDIX E APPENDIX F ORLAND PARK POLICE DEPARTMENT GENERAL ORDER ORDER NUMBER: 22-3 SUBJECT: PHYSICAL FITNESS PROGRAM EFFECTIVE DATE: March 1, 1998 AMENDED DATE: March 1, 2001
