5.4. ERMUSR 09-11-2012 - Laserfiche WebLink

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In Network Out of Network Inpatient Hospital Services 365 days of medically necessary care _Deduct'lle (hen coinsurance Deductible then 80%coinsurance. in an average semi-private room. Out•atient Hos•ital Services • Diagnostic Tests • Pre-Admission Tests and Exams E-J.icNt.e tCri C'G - n_u-anue - Deductible then 80%coinsurance. • Lab and X-Ray • Chemotherapy and Radiation Therapy - - -• Physical, Occupational and Speech - - - Therapy 0 - r: tlle nth 100.- ir ura,r;� - Deductible then 80%coinsurance. • Kidney Dialysis - _- - - - -• Scheduled Outpatient Surgery - _• Non-emergency-Illness Related visits 5 • Urgent Care(Hospital based) 0, - 1 h- j; '- E Deductible then 80%coinsurance. Emer•enc Care _ • Emergency Room nth._ _r he then 'h_ u ur-xrct-• Physician Services Ambulance - - - - - DL aintir.H .H1.- Medically necessary transport to nearest facility - - Medical Supplies Behavioral Health Care Mental Health and Chemical Dependency Caret • Inpatient Care _Door,ct le then 'r " co Deductible then 80%coinsurance. • Outpatient Care G cucuble the, ,- rnr'2c 1 Deductible then 80%coinsurance. • Professional Care Dh unic1H- (heri 111 nur_,r Deductible then 80%coinsurance. Prescri•tion Dru•s Retail-31 day limit D hunt tde r ' ' ,r;urar�e - Flex RX Formulary !I czar_ 6 _nFUn nsf _r a Pr err 1 u s IT Gene- - J+ble .4rid n-ns ticnJ .el cd uutien?(-ay' r,e d'te.rencc 90dayRx-90 day limit 1PnmeMad and Participating Retad Pharmacies) ' r ti„I_ i .r.3G'u n i I ^.in i-b- I ,pH., to r-a:,e_1 ❑d, e ritl?-'.n:'o Note:There are three drug plans available Plan A: Drugs subject to deductible then 100% Plan B: Greater of a$14 co-pay or 25%coinsurance up to a$750 per person $1,000 family drug out-of-pocket Plan C: 25%coinsurance up to a$750 per person/$1,000 family drug out-of-pocket Please discuss these plans with your account manager Deductible amounts and out-of-pocket maximums may increase annually to keep pace with inflation. *"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 items primarily used for non-medical purposes, over-the-counter drugs/nutritional supplements, services that are complementary, experimental, not medically necessary, or covered by workers' compensation or no-fault auto insurance. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Nonparticipating providers do not have contracts with Blue Cross and Blue Shield of Minnesota. Blue Cross and Blue Shield of Minnesota is an independent licensee of the Blue Cross and Blue Shield Association. Administered by Blue Cross and Blue Shield of Minnesota, a nonprofit independent licensee of the Blue Cross and Blue Shield Association