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COMMUNITY BLUES" WITH COPAY PLAN 113 <br /> WITH AWARE® NETWORK <br /> For the health of all. <br /> JULY 1, 2012 <br /> 41.., IN NETWORK OUT OF NETWORK <br /> 1 {t i'. .`ttY" 41:,:r-,r0,./.411.:tae 'd ° .a ? $0 $3,000 per person <br /> •: v �I ., 1.01'-- r . E <br /> "hq pP�t, '� �$ 4 +asR�� �w� ��i ew i , $9,000 per family <br /> 4r , , ' ," $2,000 per person $9,000 per person <br /> T + x i <br /> } . r F pub "FReIi _i $6,000 per family <br /> +2+ <br /> N� cad c h r ep riles in e8 v �4o11 $1,000 per person/$2,000 per family <br /> amour) 0 no to ee of lbdtet'tneltimu li 4 , applies to prescription drugs <br /> 6I ;,la1Fh� ' petgRtt` xl' r' u,a,? Unlimited <br /> P ' ) zpu . . c <br /> r ' fai art �9 aQ@19 '.y I rtl 3 . 100% 100% <br /> t n ',Ipf@e �1 ' 100% Deductible then 50%coinsurance <br /> 1, l d Yyccp3 tl4r '! s 100% Deductible then 50/o coinsurance <br /> • t t p s , tf- ., ' 100% Deductible then 50%coinsurance <br /> e c ten �exam :'9' ri r 100% Deductible then 50%coinsurance <br /> ,rye m ... r <br /> Pitt (7e t C i i1 a <br /> ;! t ells 4��p h�8SS pl'tNury h .1;t: - 100%after$30 copay Deductible then 50%coinsurance <br /> •0tr�` * n c tC-,kad) f 100%after$30 copay Deductible then 50%coinsurance <br /> • a ealth cl us - 100% Deductible then 50%coinsurance <br /> tat n5(ieimaging ; 100%;80%for inpatient services Deductible then 50%coinsurance <br /> 80% Deductible then 50%coinsurance <br /> •'aped SryedignS a- serum-, 100% Deductible then 50%coinsurance <br /> • sppctajty 100%o after for copay <br /> I - 100%;80%for inpatient services Deductible then 50%coinsurance <br /> 011.r tne,.ssippal sorvIces <br /> • ehc rngnipulat1on , 100%after$30 copay No coverage <br /> • i1C"1IctherapY 80% No coverage <br /> it bgrne ieafth care ' - ' 80% No coverage <br /> • gljysIgaltherapy,9,GF,�{V.ritgl therapy,speech thettapy 80% No coverage <br /> a behavioral health and.chemical dependency dare 100%after$30 copay Deductible then 50%coinsurance <br /> In-tlint hospital services <br /> • including behavioral health and chemical - 80% Deductible then 50%coinsurance <br /> dependency services <br /> Outpatient hospital services <br /> •diagnostic imaging 3 80% Deductible then 50%coinsurance <br /> •scheduled outpatient surgery 80% Deductible then 50%coinsurance <br /> • urgent care(hospital-based) "` 80% Deductible then 50%coinsurance <br /> • including behavioral health and chemical dependency 80% Deductible then 50%coinsurance <br /> services <br /> Emergency care 80% <br /> •emergency room - <br /> • physician charges, =:` 80% <br /> t,.ambulance(medPeailynecessa'ry!transport to the nearest'`;=; ° <br /> facility). s,, <br /> Medical S 1pptfas; !, „N n, 80% I Deductible then 50%coinsurance <br /> Blue Cross®and Blue Shield®of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association <br />