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AWARE GOLD® WITH COPAY PLAN 4 • ` MN
<br /> WITH AWARE® NETWORK
<br /> For the health of as
<br /> JULY 1, 2012
<br /> IN NETWORK OUT OF NETWORK
<br /> ¢I t a vv�.rt d `' e , xS I $0 $3,000 per
<br /> erson rY , , ,, _. y 4- .
<br /> I . + s o- -1d r F m. °i St it r. . ' c,^
<br /> $9,000 per family
<br /> G nl�Gµ It 4 t'y:is ri,i131tr+ ' xs- ar r
<br /> �F ' $1,500 per person $9,000 per person
<br /> tr--f+ +t a + r. + I r"�. i. J t fl j lir,
<br /> a r p rotgl . ' s + - $1,000 per person/$2,000 per family
<br /> , �QF IlctWed applies to prescription drugs
<br /> a d to o�° • c- Siiinbm
<br /> t, Ntlif:. ,r-0 ,at�"7 ypc utn } ;$ r Unlimited
<br /> P r .m care" t ��ty ,`'AC�' *, F.
<br /> • 'A—u .Bre AO ag8, ,�,�u ''1"{f•G 1, . 100% 100%
<br /> • n care F�5; ; i"i 3 s i 100% 100%
<br /> • ' e,ett nn -1 s, ,. °.-.r4 > 100% Deductible then 50%coinsurance
<br /> • ❑ [!r {t$ v t10 ° tit 4rr 100% Deductible then 50%coinsurance
<br /> •1.1111':","4' s'liCalaa , � 1 14' ,,: t." 100% Deductible then 50%coinsurance
<br /> • R',y x v4 4,,,n. t, ``4ta' ..., . It, 100% Deductible then 50%coinsurance
<br /> ft:Et A } +f y+ ]pd r }
<br /> ir°:3 } 100%after$25 copay Deductible then 50%coinsurance
<br /> a ld 4r ., 'lug �'
<br /> r'I a „4•18:2-i:.,0)� t , P Y
<br /> • H f re Ontd+bee0d)+ , " f , ' 100%after$25 copay Deductible then 50%coinsurance
<br /> R r f t4 - h PIUIG t.fi-grz '' 100% Deductible then 50%coinsurance
<br /> • ,-tt- lrrmagfpg ' ', ,; F 100% Deductible then 50%coinsurance
<br /> • .r f; :n)ectierte"and@ervrp , + ' 100% Deductible then 50%coinsurance
<br /> «r t ` ` 100%after$45 copay Deductible then 50%coinsurance
<br /> • , °.,. �, aka, w .:',: 100% Deductible then 50%coinsurance
<br /> ii:
<br /> ■ ,trapr09man !short m�i " 100%after$25 copay No coverage
<br /> • J RS*tli�`rapy -'' _ 100% No coverage
<br /> ;health Care;j, t',.':' ' av S 100% No coverage
<br /> •p, y1ldg tb rgpyt pcc, q r,�p speech herapy 100% No coverage
<br /> • behavioral heaps end cheml I eendency care _ 100%after$25 copay Deductible then 50%coinsurance
<br /> Iiiiiiiebt bosPitei gend" >
<br /> • mph9dinQ behavioral heaith and ghemicel 100% Deductible then 50%coinsurance
<br /> dependency services
<br /> Otttttbltlenk hospital services
<br /> • diegndaticlmaging? 100% Deductible then 50%coinsurance
<br /> • sghedgled outpatient atrrgef)+ 100% Deductible then 50%coinsurance
<br /> • urgent care(hospital-based} 100% Deductible then 50%coinsurance
<br /> • Including behavioral health and chemical dependency 100% Deductible then 50%coinsurance
<br /> sgrvlces
<br /> Emergency care 100%after$100 copay
<br /> •emergency room
<br /> • physician charges 100%
<br /> •ambulance(medicallynecessary transport to the nearest . 80%
<br /> facility+)
<br /> MedlSateuppl1eei,_> ,. 80% I 50%
<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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