5.4. ERMUSR 09-11-2012 - Laserfiche WebLink

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IN -NETWORK PROVIDERS OUT-OF-NETWORK PROVIDERS npatient Hospital Services 365 days of medically necessary care -100% Deductible then 80%coinsurance in an avera.e semi-private room Out•atient Hos t ital Services • Diagnostic Tests • Pre-Admission Tests and Exams 100% Deductible then 80%coinsurance • Lab and X-Ray • Chemotherapy and Radiation Therapy • Physical, Occupational and Speech Therapy x u A • Kidney Dialysis 100% Deductible then 80%coinsurance • Scheduled Outpatient Surgery • Non-emergency— Illness Related visits • Urgent Care(Hospital based) '1100% Deductible then 80%coinsurance Eme tenc Care • Emergency Room x100%after$75 co pay • Physician Services "100%e 100% Ambulance - Medically necessary flansporT to nearest r�c0ity r " Medical Supplies Behavioral Health Care Mental Health and Chemical Dependency Care) • Inpatient Care -10,0% `;„-e, = Deductible then 80%coinsurance • Outpatient Care "100°4 '' Deductible then 80%coinsurance • Professional Care 2100%after.$20 office Gall copay,,; Deductible then 80%coinsurance. Prescri s tion Dru.s •etail—31day limit '$0 Co-pay g"@neric '" $35 Co-pay'Bra'nd Formulary $50 Co-pay Brand Non:formulan 90dayRx—90 day limit '$0 Co=pay genenc , ' (PruneMail and Participating Retail y$70 Co-pay;Brand Formulary .,r y Pharinacles) �$125 Co-pay,Brand Non::-formulary ` **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.