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Faculty & Staff

Risk & Benefits Management

Medical Benefits

Medical Benefits are payable at the listed amounts after satisfying a $250 deductible per person ($500 per family) for expenses incurred in a calendar year to a lifetime limit of $3,000,000. Reasonable and customary charges apply.

The $250 deductible will be applied to all health benefits with the exception of dental, vision, prescription drugs, and the wellness benefits.

The out-of-pocket limit, excluding the deductible, is $1,000 per person ($2,000 per family) per calendar year. This limit, however, does not apply to dental or vision benefits, prescription drug co-pays, to employee wellness benefits, to expenses payable at 50%, to amounts which are over reasonable and customary, or to other non-covered expenses.

Payable at 100%
Reasonable and customary physician fees and hospital charges are payable in full, subject to the calendar year deductible, for the following:

Out-patient Surgery
Whenever rendered when you are not a hospital bed patient overnight.

Out-patient Diagnostic Tests
When related to a specific condition or medical complaint.

Out-patient Accident Initial Care
Within 72 hours following an accident and follow-up out-patient care within 90 days of an accident.

Out-patient Medical Emergency Care
In non-accident cases, for the sudden onset of a condition which would result in permanent medical consequences in the absence of immediate medical attention.

Examples: loss of repiration, heart attack, profuse nose bleed, food poisoning, acute bronchitis attack and convulsions.

Examples of conditions not considered medical emergencies: upper respiratory infection, urinary tract infection, and temperature less than 102.

Payable at 90% *
After a $250 deductible per person ($500 per family) for expenses incurred in a calendar year, the Plan will pay 90% of reasonable and customary charges, subject to the limitations and exclusions specified, to a lifetime maximum of $3,000,000, for the following:

  • Hospital room and board charges up to a hospital’s most common semi-private rate; full charges for intensive care, coronary care or special care units; and in-patient or out-patient miscellaneous services and supplies provided by a hospital when necessary to treat a condition of illness or injury. Admissions extending beyond 23 hours will be treated as in-patient services.
  • Physician fees for office calls and other professional services. When multiple surgical procedures are performed, the reasonable and customary allowance will be adjusted.
  • Routine exams, immunizations/vaccinations, and school physicals would be covered for reasonable and customary charges for children through the age of 18.
  • Physical or occupational therapy when performed by a registered physical or occupational therapist (or licensed therapist assistant or certified occupational therapy assistant working under the direction of a registered physical or occupational therapist).
  • Charges of a licensed speech therapist to restore speech loss due to an injury, stroke or surgery.
  • In-hospital insulin and drugs and medicines prescribed by a physician. TPN or other medically necessary intravenous or injectable drug therapy, but only from a vendor approved by the Plan on a case by case basis, if the cost of the medication exceeds $500 per month.
  • Leg, arm, neck and back braces or services of a registered physical therapist (or licensed physical therapist assistant working under the direction of a registered physical therapist) only when prescribed by a physician.
  • Professional ambulance service when medically necessary to transport a patient to the nearest hospital where required medical treatment can be provided. Ambulance service is provided from a hospital to a nursing home or to the individual’s home when approved by the Claims Administrator.
  • Durable medical equipment rental, or purchase thereof at the option of the Claim Administrator, when prescribed by a physician and where such rental equipment is not used customarily except for medical purposes.
  • Hospice, home health care, or services of private duty nurse when such individual normally does not reside in the patient’s home, if prescribed by a physician and if pre-approved by the Claim Administrator.
  • Artificial limbs and other prosthetic applications for accidents or illnesses incurred while covered under this Plan or the program it replaced.
  • Oxygen, blood and related administration charges.
  • Surgical and related supplies which are primarily only for medical purposes.
  • Hearing aids and batteries with a maximum $1,000 limit per person per year with 50% coverage for batteries.

* 50% for hospital and related physician fees when care is received in Peoria County at other than the Methodist Medical Center if (1) the care is available at Methodist, or (2) any additional time required to transport the patient to Methodist would not jeopardize the patient’s health, or (3) an exception is not made by the Plan due to extenuating circumstances. This provision does not apply to care received outside of Peoria County or to those Plan participants who select the Freedom of Choice option.