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IN NETWORK OUT OF NETWORK
<br /> 4
<br /> a. . - - - $12 copay $12 copay
<br /> s $45 copay $45 copay
<br /> - - $90 copay $90 copay
<br /> 20%to a maximum of$200 per No coverage
<br /> { prescription
<br /> 'i ° 9
<br /> A $24 copay
<br /> - - - $90 copay
<br /> ifilliaWItarff=-14amfratepcirefr 410 -$180 copay.-------------
<br /> 90dayRx applies to participating and/or mail service pharmacy.
<br /> Identified specialty drugs purchased through a specialty pharmacy network
<br /> W4,1014,50410042,100545fianyeet". supplier are eligible for coverage(no coverage for specialty drugs purchased
<br /> through a nonparticipating specialty pharmacy supplier).
<br /> s ,k ,{ ry . a a ,. The patient will pay the difference if a brand-name drug is selected when a
<br /> Is $ - ° a? i4 a ' generic drug is available.
<br /> r '', 4.. „' The drug list uses a step therapy program.Visit the prescription drugs section
<br /> kt `'u ; m " of www.bluecrossmn.corn for more details.
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<br /> s1444 c'" . ;r-?..- ems msti-II4 )4:9- : f44j+c444.
<br /> Your out-of-pocket costs depend on the network status of your provider.To check the status of a provider,call Blue Cross and Blue Shield of Minnesota
<br /> customer service or visit bluecrossmn.com.
<br /> Lowest out-of-pocket costs:in-network providers
<br /> Higher out-of-pocket costs:extended and out-of-network participating providers
<br /> Highest out-of-pocket costs:out-of-network nonparticipating providers(You are responsible for the difference between Blue Cross'allowed amount
<br /> and the amount billed by nonparticipating providers.This is in addition to any applicable deductible,copay or coinsurance.Benefit payments are
<br /> calculated on Blue Cross'allowed amount,which is typically lower than the amount billed by the provider.)
<br /> This is only an outline of plan benefits.The contract and certificate include complete details of what is and isn't covered.Services not covered include
<br /> eyeglasses,hearing aids,items primarily used for a non-medical purpose,over-the-counter drugs(except as specified in the Certificate of Coverage),
<br /> nutritional supplements,services that are cosmetic,experimental,not medically necessary,or covered by workers'compensation or no-fault auto
<br /> insurance.Preexisting conditions may not be covered for a limited period of time.This limit is reduced by prior continuous coverage and doesn't apply to
<br /> pregnancy,newborns,adopted children,individuals under 19 or handicapped dependents.We feature a large network of health care providers.
<br /> Each provider is an independent contractor and is not our agent.Nonparticipating providers do not have contracts with Blue Cross and Blue Shield of
<br /> Minnesota.Please note:Benefits are subject to regulatory approval.
<br /> UNMATCHED SERVICE HEALTH AND WELLNESS TOOLS
<br /> When you call customer service,Health Guides answer your questions, You get a comprehensive suite of health support offerings including:24-
<br /> resolve any issues and refer you to additional resources that can help you Hour Nurse Advice Line,Dedicated Nurse Support for ongoing
<br /> save money and live a healthy life. health conditions,Employee Assistance Program,Enhanced Stop-
<br /> Smoking Support,Fitness Discounts,Health Guides and Nurse Guides,
<br /> HEALTH CARE COVERAGE ANYWHERE IN THE WORLD Healthy Start®Prenatal Support,Online health assessments,Online
<br /> More than 97 percent of Minnesota doctors and hospitals are in our health coaching
<br /> networks,where you always get the best benefit for your dollar.And you
<br /> never need a referral.You're also"in network"virtually anywhere you ONLINE CARE ANYWHERE"-"
<br /> go in the United States with the BlueCard®traditional network and Talk to a provider online,when it's convenient for you.Online Care
<br /> internationally through the BlueCard Worldwide®network. Anywhere gives you online access to providers who can answer
<br /> To find in-network providers,visit"Find a doctor"at bluecrossmn.com. questions,make diagnoses and prescribe medications as appropriate—
<br /> For providers in Minnesota,search the Aware®network. all from your home or office.For information,go to
<br /> O nlineCareAnywhereMN.com.
<br /> SAVE MONEY ON BETTER HEALTH *Note:Available only in Minnesota.Visits are not covered by your
<br /> You'll get discounts on:Acupuncture and massage therapy,Weight health plan;therefore,payments do not apply toward your deductible.
<br /> Watchers,LASIK eye surgery,Medical equipment,Disposable medical
<br /> supplies and more END-OF-YEAR DEDUCTIBLE CARRYOVER
<br /> When you haven't met your calendar-year deductible,you can"carry
<br /> QUICK,HASSLE-FREE CLAIMS PROCESSING over"approved claims expenses incurred in October,November and
<br /> Your claims are handled quickly,efficiently,accurately and without December to help meet the deductible for the following year.The annual
<br /> hassle. out-of-pocket maximum begins again in January of each year.
<br /> For more information,contact your employer or visit bluecrossmn.com.
<br /> Blue Cross®and Blue Shield®of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association
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