6.1. ERMUSR 11-09-2004 - Laserfiche WebLink

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awareg `-' I Please note:Benefits are subject to regulatory i...„.,L ith copay plan p � v' '• *RR'i' Sr'sy'`xuodext P� r a IN-NETWORK EXTENDED/.OUT-OF-NETWORK• x -su`rc r k �S. e`IFiN ' f(fRkgp z+l'hYs L ival deductible none $300/person-$900/family $5,000/person Out-of-pocket maximum • $2,500/person A separate out-of-pocket maximum 1. of$500 per person applies to prescription drugs , $3 million tot•sen /Ices from all providers Lifetime maximum LOffice visits Behavioral health care(mental health, 00% after$15 copay 80% after deductible • B • Behavioral or Injury 100% after$15 copay* (see details below) 80% after deductible substance abuse, eating disorders and autism) • Chiropractic manipulation 100°/3 after $15 copay*(see details below) 80% after deductible, no benefits for _ ` P services from out-of-network providers • r Preventive surgery/allergy-related services 100% 80% after deductible LPreventive care 100% °/ after deductible • Well-child services and immunizations 100% 80 80% after deductible • Prenatal care - 80% after deductible • Routine physicals and eye exams 100% • Cancer screenings 100% 80% after deductible Lab and X-ray services 100% 80% after deductible ��In-and outpatient hospital services 100%+(see details below) 80°/o after deductible IIII • Facility services(includes behavioral health care) SO% after deductible • Professional services(includes behavioral 100%*(see details below) health care) emergency care 10C% after$6G copay Facility services 100% after$60 copay Professional services - 100% 803/0 after deductible Ambulance services 80% 80% Medical supplies 80 80% Therapy services + 80% after deductible, no benefits for • Chiropractic therapy 100% after$15 copay (see details below) services from out-of-network providers 100% after $15 copay 80% after deductible"".(see details below) • Occupational and physical therapy 100% after $15 copay 80% after deductible** (see details below) • Speech therapy Prescription drugs 80% coverage, member responsible for a • 31-day supply, 3-cycle supply of oral 80% coverage,member responsible for a of$10 and a maximum of $30 minimum of $10 and a maximum of$30:you contraceptives for 3 copays,formulary minimum cr.gsbnly Per prescription pay the pharmacy and file a claim In addition _ , . to copays, member will be responsible for amounts in excess of the allowed amount. • Mail-order drugs(90-day supply) 100% after $40 copay How cost sharing is calculated. Copays are flat fees you pay at the time you receive a service. Coinsurance is the percentage of charges you pay for a service. Its based on the allowed amount Deductible charges are subtracted from the allowed amount. Allowed amount is the negotiated amount that network providers have agreed to accept as full payment at the time your claim is processed. If you see a provider who doesn't participate with Blue Cross,the allowed amount is either the billed charge or a percentage of the network allowed amount, whicneve• is less. PI • For highest level of coverage,use Select Network providers for outpatient chiropractic and behavioral health services. For all other services use the Blue Cross Network. � '"Physical,occupational and speech therapy services limited to a$500 maximum per calendar year c . (�'� This is only an outline of plan benefits Tne contract and certificate induce complete details or what is and isn t covered nts Sere c s not c are edsmeude eyeglasses,hearing aids,items primarily used for a non-medical purpose,over the-counter drugs/nutit onai supp Bluecross Blueshield experimental,not medically necessary.or covered by workers'compensation or no-fedi:auto insurance.Pre-existing nS ndoptns rea diet be covered for of Minnesota a limited period of time.This limit is reduced by prior continuous coverage and doesn't apply pregnancy dependents.We feature a large network of neeith care providers.Each provider is an independent contractor and is not our agent Nonparticipating lyreSRls i9/04i providers do not have contracts with Blue Cross and Blue Shield of Minnesota Blue cross and Blue Shield of Minnesota is an independent licensee Sian numye n'. of the Blue Cross and Blue Shield Association.Benefits are effective Ian 2005