5.4. ERMUSR 09-11-2012 - Laserfiche WebLink

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IN NETWORK I OUT OF NETWORK . _ - ' Cr7; $12 copay $12 copay -; .va $45 copay $45 copay 3y ii> - _ $90 copay $90 copay +''i a 20%to a maximum of$200 per No coverage j c prescription SB 3 - - $24 copay - _ - - w„ $90 copay - =e $180 copay— -------- -------- 90dayRx applies to participating and/or mail service pharmacy. il Identified specialty drugs purchased through a specialty pharmacy network supplier are eligible for coverage(no coverage for specialty drugs purchased se wog ”; ,'fl through a nonparticipating specialty pharmacy supplier). f +HIV,k a The patient will pay the difference if a brand-name drug is selected when a I.trori4. generic drug is available. t' E. `; ' ,qis The drug list uses a step therapy program.Visit the prescription drugs section rgitiVedtre'7.,y p,{ ' ' i it 1Y+ of www.bluecrossmn.com for more details. AT7... 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 customer service or visit bluecrossmn.com. Lowest out-of-pocket costs:in-network providers Higher out-of-pocket costs:extended and out-of-network participating providers Highest out-of-pocket costs:out-of-network nonparticipating providers(You are responsible for the difference between Blue Cross'allowed amount and the amount billed by nonparticipating providers.This is in addition to any applicable deductible,copay or coinsurance.Benefit payments are calculated on Blue Cross'allowed amount,which is typically lower than the amount billed by the provider.) 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 eyeglasses,hearing aids,items primarily used for a non-medical purpose,over-the-counter drugs(except as specified in the Certificate of Coverage), nutritional supplements,services that are cosmetic,experimental,not medically necessary,or covered by workers'compensation or no-fault auto 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 pregnancy,newborns,adopted children,individuals under 19 or handicapped dependents.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.Please note:Benefits are subject to regulatory approval. UNMATCHED SERVICE HEALTH AND WELLNESS TOOLS When you call customer service,Health Guides answer your questions, You get a comprehensive suite of health support offerings including:24- resolve any issues and refer you to additional resources that can help you Hour Nurse Advice Line,Dedicated Nurse Support for ongoing save money and live a healthy life. health conditions,Employee Assistance Program,Enhanced Stop- Smoking Support,Fitness Discounts,Health Guides and Nurse Guides, HEALTH CARE COVERAGE ANYWHERE IN THE WORLD Healthy Start®Prenatal Support,Online health assessments,Online More than 97 percent of Minnesota doctors and hospitals are in our health coaching networks,where you always get the best benefit for your dollar.And you never need a referral.You're also"in network"virtually anywhere you ONLINE CARE ANYWHERE` go in the United States with the BlueCard®traditional network and Talk to a provider online,when it's convenient for you.Online Care internationally through the BlueCard Worldwide®network. Anywhere gives you online access to providers who can answer To find in-network providers,visit"Find a doctor"at bluecrossmn.com. questions,make diagnoses and prescribe medications as appropriate For providers in Minnesota,search the Aware®network. all from your home or office.For information,go to Onli neCa reAnyw hereMN.com. SAVE MONEY ON BETTER HEALTH *Note:Available only in Minnesota.Visits are not covered by your You'll get discounts on:Acupuncture and massage therapy,Weight health plan;therefore,payments do not apply toward your deductible. Watchers,LASIK eye surgery,Medical equipment,Disposable medical supplies and more END-OF-YEAR DEDUCTIBLE CARRYOVER When you haven't met your calendar-year deductible,you can"carry QUICK,HASSLE-FREE CLAIMS PROCESSING over"approved claims expenses incurred in October,November and Your claims are handled quickly,efficiently,accurately and without December to help meet the deductible for the following year.The annual hassle. out-of-pocket maximum begins again in January of each year. For more information,contact your employer or visit bluecrossmn.com. Blue Cross®and Blue Shields of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association