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BlueCross BlueShield Elk River Municipal Utilities <br /> Vas) of Minnesota <br /> • • .. r A,,.,•rithi "r,AS„,,":h„a.,,os„" Double Gold Ne CAA-lei-EMT PL 44" L-3C <br /> Effective Date: 1/1/2013 <br /> THIS IS ONLY A SUMMARY AND IS SUBJECT TO THE TERMS OF THE CONTRACT** <br /> IN - NETWORK PROVIDERS OUT-OF-NETWORK PROVIDERS <br /> Calendar Year Deductible <br /> $0 Single $0 Family $300 Single $900 Family <br /> Medical <br /> Calendar Year Out-of-Pocket Maximum $1,500 per person In Network <br /> $5,000 per person Out of Network `` <br /> Non i overeii i barges and charges in <br /> excess of our allowed amount do not Prescription <br /> apply to the out-of-pocket maximum <br /> $750 Single $1,500 Family <br /> Coinsurance 100% Deductible then 80%coinsurance <br /> If non-participating provider services are <br /> 'Payment for Participating Network covered,you are responsible for the <br /> Benefit Payment Levels Providers as described. Most payments difference between the billed charges and <br /> are based on allowed amount allowed amount. Most payments are <br /> based on allowed amount. <br /> Lifetime Maximum per Person Unlimited <br /> Dependent Child Age Limit To age 26, through the calendar month of the birthday. <br /> COVERED CHARGES <br /> Preventive Care <br /> • Well Child Care through age 5 100% 100% <br /> • Prenatal Care <br /> • Routine Physicals ages 0 and older <br /> • Office Visits <br /> • Cancer Screening 100% Deductible then 80% coinsurance. <br /> • Routine F fearing arid Vision Exams <br /> • Imrnun'¢alicns and Vaccinations - - <br /> Ph sician Services <br /> • In-Hospital Medical Visits <br /> • Surgery and Anesthesia 100% Deductible then 80%coinsurance. <br /> • Inpatient Lab and X-rays.etc <br /> • Office Visits due to Illness or Injury 100%after$20 co-pay Deductible then 80% coinsurance. <br /> • Urgent Care (Clinic Based) <br /> • Outpatient Lah and X-ray 100% Deductible then 80%coinsurance. <br /> • Allergy Injections and Serum 100% Deductible then 80%coinsurance. <br /> Other Professional Services <br /> • Chiropractic Care 100%after$20 co-pay with Blue Select Deductible then 80%coinsurance with <br /> providers. - Extended Network providers. No coverage <br /> with non•artici•atin• •roviders. <br /> • Home Health Care 100% Deductible then 80%coinsurance <br /> • Physical Therapy, Occupational <br /> Therapy, Speech Therapy 100%after$20 co-pay Deductible then 80%coinsurance. <br /> $500 maximum benefit per calendar year <br /> for non-participating providers. <br />