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Todd James
Personalized just for you
See inside for information about your 2022 health plan
2022
102233.1021
Your current health plan will be renewed for 2022, with some changes.
Your 2022 Health Plan
StayBlueIL.com
October 20, 2021
Prepared for: Todd James
Member ID number: 012345678
Authorized agent: Taylor Johnson
Key Dates
•
•
•
Questions?
November 1: Open enrollment begins.
January 15: Open enrollment ends.
January 1: The 2022 plan year begins. First payment is due.
See inside back cover for our phone number and hours.
Your Estimated Monthly Payment Amount
Thank you for being a member of Blue Cross and Blue Shield of Illinois (BCBSIL). Your current
health plan, BlueCare Direct Silver 212 with Advocate, will be renewed for 2022.
2021 2022
Premium Before Subsidy $822.44 $890.23
Subsidy $660.00 To be determined.
Premium with 2021 Subsidy $162.44
$230.23
2022 subsidy details aren’t available yet.This is an estimate of your monthly paymentbased on your 2021 subsidy.
For more information about your 2022 subsidy, go to StayBlueIL.com.
If you or someone you know is ready to begin planning for Medicare, we are here to help. To learn more, visit
getblueil.com. You can also call 855-218-6376, or contact your independent, authorized Blue Cross and Blue Shield of
Illinois agent.
You will receive your 2022 member ID card(s) beforethe end of the year.
You will also receive a welcome kit with helpful information about
your plan. Sign up at StayBlueIL.com to receive your welcome kit
electronically instead of by mail.
1. You Can Renew or Shop
Renew Your Plan Shop for a Different Plan
• Just keep making your monthly payments and
you'll be re-enrolled in your current health plan.
• Some plan benefits, like copays and
coinsurance amounts, may change in 2022. See
Benefit Changes on the next page.
• Visit StayBlueIL.com or call your authorized BCBSIL
agent between November 1 and January 15, during
open enrollment.
• If you were enrolled in Auto Bill Pay, you will need
to re-enroll by visiting PayBlueIL.com or by calling
us at 1-800-538-8833.
Please note: The doctors and hospitals in a plan’s network may change.Visit StayBlueIL.com to confirm your providers are in your plan’s network.
2. Make Your Payment by January 1, 2022You can pay or enroll in Auto Bill Pay at PayBlueIL.com.
3. Look for Your Member ID Card and Benefit Information
Get Ready for 2022
If you do nothing, your health plan will renew on January 1.
StayBlueIL.com
Benefit Changes
Your Out-of-Pocket Costs
The terms below help explain your out-of-pocket costs.
Deductible • The amount you pay for most covered services before your health plan starts to pay.
• When you go to a provider that is in the plan's network, before you meet the deductible
you pay a discounted amount that has been negotiated with the provider.
• The deductible resets at the beginning of the calendar year or when you enroll in a
new plan.
Copay • The set dollar amount you pay for a covered health care service at the time you
receive care or when you pick up a prescription drug.
Coinsurance • The percentage of the costs of a covered health care service or prescription drug you
pay after you've paid your deductible.
• You pay 100 percent of the full allowed amount until you meet your deductible.
Out of Network • Services are considered out of network when you use a doctor or other provider that
does not have a contract with your health plan.
• Out-of-network services may not be covered or may be covered at a lower level.
• You may be responsible for all or part of an out-of-network provider's bill.
Individual
and Family
Out-of-Pocket
Maximums
• The most you have to pay for covered services in a plan year.
• After you spend this amount on deductibles, copays and coinsurance, your health plan
pays 100 percent of the costs of covered benefits.
• For plans that cover more than one person, individual out-of-pocket maximums count toward
the family out-of-pocket maximum. Once the family out-of-pocket maximum is reached, the
plan pays 100 percent of the cost of covered benefits for everyone on your plan.
• The out-of-pocket maximum doesn't include your monthly premium payments or
anything you spend for services your plan doesn't cover.
For the full list of terms, please visit BlueGlossaryIL.com.
StayBlueIL.com
Review some benefit changes startingJanuary 1, 2022.
StayBlueIL.com
Here Are Some Plan Changes
• In 2022, the number of services that need prior authorization may change. Please see your 2022 Benefit Book for
services that need prior authorization.
• Please review the 2022 drug list at BlueRxIL.com to see if the drugs that you take or are prescribed are affected by any
changes. For example, a drug may have moved to a lower or higher drug tier.
• Starting January 1, 2022, benefits are no longer available for non-emergent, self-referred Mental Health or Substance
Use Disorder treatment received out of network that are not authorized or referred by your Primary Care Physician
(PCP) or Woman’s Principal Healthcare Provider (WPHCP).
This is not a complete list of benefit changes.For a more complete summary of your benefits, see the enclosed Summary of Benefits and Coverage for 2022, also
available online at BlueBenefitSummaryIL.com/56/.
About Dental CoverageIf you don’t have a separate BCBSIL dental plan: When you bought your health plan from BCBSIL, you told us you
have what is known as an “exchange-certified stand-alone dental plan,” which provides coverage for the “Pediatric Dental
Essential Health Benefit (EHB).” Please contact us if you no longer have this required coverage. If we don’t hear from you,
our records will show that you have the Pediatric Dental EHB from another insurance company.
Benefit Changes continued
How to Read Drug Lists
The example below from the
drug list shows a drug that:
• Is in tier 5
(preferred specialty drug)
• Requires prior authorization
•
TierDrug
Type
Your
Cost
6 Non-Preferred Specialty $$$
5 Preferred Specialty
4 Non-Preferred Brand
3 Preferred Brand
2 Non-Preferred Generic
1 Preferred Generic $
Some Drugs Have Additional Requirements
• Some medicines on the drug list may have additional
requirements, such as prior authorization.
• Check the drug list to see if any drugs you take have these
additional requirements.
Example drug – for subcutaneous inj 25 mg
Pharmacy Informationand Prescription DrugChanges
Changes to your pharmacy benefitprogram will start on January 1, 2022.
Visit BlueRxIL.com to see if any of these changes may affect your drugs or coverage. If
you are affected by these changes, talk to your doctor about your treatment options.
Some Drugs Will Move to a Different Drug Tier
• Your health plan uses drug tiers. In general, the lower the tier,
the lower your out-of-pocket costs.
• Drugs may move to a lower or a higher tier.
• View the drug list at BlueRxIL.com to see your drug's tier.
StayBlueIL.com
Has a dispensing limit
You can download the drug list
at BlueRxIL.com.
StayBlueIL.com
Pharmacy Information andPrescription Drug Changes continued
Changes in Coverage for Commonly Used Drugs
Commonly Used Drugs That Will No Longer Be Covered as of January 1, 2022
Generic Brand Specialty
CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL
1-5% (non-refrigerated)
HALOBETASOL 0.05% Ointment
INVOKAMET SEGLUROMETNO
CHANGES
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% Lotion
HYDROCODONE/APAP 5-300 Mg, 7.5-300 Mg, 10-300 Mg
TabletsINVOKAMET XR STEGLATRO
COLESEVELAM PAK 3.75 Gm
METHYLPHENIDATE 2.5 Mg, 5 Mg, 10 Mg Chew Tablets
INVOKANATAZORAC
0.05%, 0.1% Gel
DESONIDE 0.05% Lotion
METRONIDAZOLE LOTION 0.75%
MITIGARE 0.6 Mg Capsules
TRUVADA
DILTIAZEM ER (Coated Bead Tablets)
MORPHINE SULFATE ER 10 Mg, 20 Mg, 30 Mg, 50 Mg, 60
Mg, 80 Mg, 100 Mg CapsulesQTERN
DOXYCYCLINE MONOHYDRATE 150 Mg Tablets
OXYCODONE 5 Mg Capsules
EC-NAPROXEN 375 Mg, 500 Mg Tablets
TRETINOIN 0.025%, 0.05% Gel
FENOPROFEN 600 Mg Tablets
Please note:
• For commonly used drugs that are no longer covered, a covered generic or brand alternative may be available. Ask
your doctor about therapeutic alternatives.
• Commonly used drugs that are no longer covered may not apply to all strengths/formulations.
• Some benefit plans may have preventive drug benefits. This means you may pay a lower cost, as low as $0, for
preventive care drugs.
• If your plan has these preventive drug benefits, and coverage for your prescription changes, the amount you pay
under the preventive drug benefit may also change.
• Drugs that have not received U.S. Food and Drug Administration (FDA) approval are not covered.
• Some drugs may be covered under your medical plan instead of your pharmacy benefits. These can include drugs
that must be given to you by a health care provider. If you are taking or prescribed a drug that is not on your plan's
drug list, call the number on your member ID card to see if the drug may be covered by your medical plan.
Some drugs may no longer be covered under your plan. For complete lists of drugs that are
newly covered or no longer covered as of January 1, 2022, visit BlueRxIL.com.
Pharmacy Information
You can save money by using an in-network pharmacy.
In-Network Pharmacies
$
Your out-of-pocket costs are generally lower at an in-network pharmacy than
at a pharmacy that is out of network.
Reminder: 90-Day Supply
For your convenience, you can fill up to a 90-day supply of most covered drugs
at select pharmacies in your plan’s network or through home delivery.
Visit myprime.com to find in-network pharmacies.
Pharmacy Information and Prescription Drug Changes continued
StayBlueIL.com
Coverage is based on the limits and terms noted in your plan materials. For some medicines, members must meet certain criteria before prescription drugbenefit coverage may be approved. See your plan materials for details. As always, treatment decisions are between you and your doctor.
Prime Therapeutics LLC is a separate pharmacy benefit management company contracted by Blue Cross and Blue Shield of Illinois (BCBSIL) to providepharmacy benefit management and other related services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The relationshipbetween BCBSIL and contracting pharmacies is that of independent contractors. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, hasan ownership interest in Prime Therapeutics.
Myprime.com is an online resource offered by Prime Therapeutics LLC.
Out-of-Network
Pharmacies
$$$
Generally, your
out-of-pocket costs
are highest at an
out-of-network pharmacy.
Your new premium
StayBlueIL.com
Government-Required Notice
October 20, 2021
Important: It’s time to review your health coverage. Take action by December 15, 2021, or you’ll be
automatically re-enrolled in the same or similar coverage. This may change some of your costs and
coverage, so review your options carefully.
Thank you for choosing Blue Cross and Blue Shield of Illinois (BCBSIL) for your health care needs. We’re here tohelp you prepare for Open Enrollment.
Why am I getting this letter?
Your health coverage is still being offered in 2022, but some details may have changed. Read this letter carefully and
decide if you want to keep this plan or choose another one. Also make sure to update your information with the
Exchange.
Changes you’ll see to your plan in 2022
• Your 2021 monthly payment is $162.44.
This reflects a monthly premium of $822.44 minus $660.00 of financial help per month.
• Your new monthly payment starting in January is estimated to be $230.23.
This reflects an estimated monthly premium of $890.23 minus the same amount of financial help you’re getting
now. However, your financial help may be different next year. You’ll see your new monthly payment when
you receive your January bill.
Important: This estimated monthly payment is based on current information we have for 2021. It might not
account for some or all changes that could impact your monthly payment, like cost changes in your area for next
year, or changes to your household income or family size. To find out the actual amount of your monthly payment,
update your Exchange application. See below for more information.
Other changes
• Please see the enclosed Benefit Changes section.
• You can review more details about your plan at StayBlueIL.com and in your 2022 Summary of Benefits and
Coverage.
StayBlueIL.com
Government-Required Notice continued
What you need to do
1. Update your Exchange application by January 15.
Review your Exchange application to make sure the information is still current and correct, and to see if you qualify
for more or less financial help than in 2021. This may result in a lower monthly premium payment or lower
out-of-pocket costs (like deductibles, copayments, and coinsurance). Plus, you can help avoid paying money back
when you file your taxes.
2. Decide if you want to enroll in this plan or choose another one.
I want to enroll in this plan.
Update your Exchange application information, and then select BlueCare Direct Silver 212 with Advocate
36096IL0950018-02 to enroll.
I want to pick a different plan.
You can choose a different plan between November 1, 2021, and January 15, 2022. Enroll by December 15, 2021,
for coverage to start January 1.
Here are some ways to look at other plans and enroll:
• Visit healthcare.gov to see other Exchange plans. Consumers who shop can save hundreds of dollars per year
and can find a plan that best meets their needs and budget.
• Check with BCBSIL to see what other plans may be available. Remember, you won’t get financial help unless
you qualify and enroll through the Exchange.
Note: If you got financial help in 2021 to lower your monthly premium, you’ll have to “reconcile” using IRS Form
8962 when you file your federal taxes. This means you’ll compare the amount of premium tax credit you received
in advance during 2021 with the amount you actually qualify for based on your final 2021 household income and
eligibility information. If the amounts are different, this will affect the amount of your refund or taxes owed.
We’re here to help
• Visit healthcare.gov, or call 1-800-318-2596 (TTY: 1-855-889-4325) to learn more about the Exchange and to see if
you qualify for lower costs.
• Call Blue Cross and Blue Shield of Illinois at 1-800-538-8833 or visit bcbsil.com.
• Find in-person help from an assister, agent, or broker in your community at LocalHelp.Healthcare.gov.
• Contact an agent or broker you’ve worked with before like Taylor Johnson. Call 855-414-6175.
• Call 1-800-318-2596 (TTY: 1-855-889-4325) for a reasonable accommodation to get this information in an accessible
format, like large print, Braille, or audio, at no cost to you.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services +. ll BlueCross BlueShield or lllinois : BlueCare Direct S ilverSM 212 with Advocate
Coverage Period: 01/01/2022 -12/31 /2022 Coverage for: Individual/Family I Plan Type: HMO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www .bcbsil.com/bblind/bb-
sh2h30bhdiilp-i�2022.pdf or by calling 1-80�892-2803. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.
What is the overall deductible? Are there services covered before you meet your deductible?
$0
Yes.
Are there other deductibles I No for sp_ecific services? What is the out-of-pocket I Not Applicable l imit for th is .P.!!!1? What is not included in the out-of-_pocket limit?
Not Applicable
Will you pay less if you use IYes. See www.�cbsil.com or call 1-80�
a network provider? 892-f803 for a I 1st of Participating Providers.
Do you need a referral to see a s2ecialist? Yes.
See the Common Medical Events chart below for your costs for services this plan covers.
This plan covers some items and services even if you haven't yet met the deductible amount. But acopayment or coinsurance may apply.
You don't have to meet deductibles for specific services.
This plan does not have an out-of-pocket limit on your expenses.
This plan does not have an out-of-pocket limit on your expenses. This plan uses a provider network. You will pay less if you use a provider in the plan's network. Youwill pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as labwork). Check with your .PrQY!Qfil before you get services. This plan will pay some or all of the costs to see a specialist for covered services but only if youhave a referral before you see the fil?_ecialist.
Blue Cross and Blue Sl'ield of Ill i nois, a Div is ion of Heallll Care SelVice Corporation, a Mulual Legal Reserve Company, an lndependenl Licensee of the Blue Groos and Bl ue S h ie ld Assoc iation
SBC IL HMO IND-2022 Page 1 of?
Notes
StayBlueIL.com
Notes
StayBlueIL.com
Notes
StayBlueIL.com
Help is Available
• Find in-network doctors and hospitals.
• Sign up to get your health plan information electronically instead of by mail.
• Review other health plan options and connect to our online shopping experience.
• Download the mobile app to access all these features and more.
Still have questions?
If you have questions, contact your authorized BCBSIL agent, Taylor Johnson, or call
855-414-6175. We are available:
• Monday through Friday: 8 a.m. to 8 p.m. CT
• Saturday: 8 a.m. to 6 p.m. CT
• Sunday: 10 a.m. to 2 p.m. CT
Expect longer wait times closer to January 15, when open enrollment ends.
For more information, visit or call:
Health Insurance Marketplace
• healthcare.gov
• 800-318-2596
Office of Consumer Health Insurance (OCHI)
• http://insurance.illinois.gov/healthinsurance/consumerHealth.html
• 877-527-9431
StayBlueIL.com
Visit StayBlueIL.com to:
P.O. Box 660819 • Dallas, TX 75266-0819
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal ReserveCompany, an Independent Licensee of the Blue Cross and Blue Shield Association