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.

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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.

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Review some benefit changes startingJanuary 1, 2022.

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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

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Notes

StayBlueIL.com

Notes

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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