6.1. ERMUSR 11-09-2004 - Laserfiche WebLink

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y'i �.1 1-� (1 (11 ` f 1 r k" f 1 f I ) (. w I t h C O p n 1' p 1 a 11 Please note e eOrs are cub ngirramry pproval N R r "Or( 'I.�tV Ott trr-"#3iRS Annual deductible none 5200/person—$600/family Out-of-pocket maximum Q $1,100/person—$5,000/family 0 52,500/person A separate out-of-pocket maximum Q $1,300/person—$5,000/family 0 $2,500/person of$500 per person or 51,000 per family applies to prescription drugs. Lifetime maximum $3 million for services from all providers Office visits • Illness or Injury 100%after 08/5 copay or 0525 copay * 60% after deductible • Behavioral health care(mental heath, 100% after Q$15 copay or 0$25 copay * 60% after deductible substance abuse,eating disorders (rev scrods ddo+d and autism) • Chirop'actic manipulation 100%after Q $15 copay or 0825 copay * 60% after deductible, no benefits for treederaih ceiow/ services from out-of-network providers • In-office surgery/allergy-related services 80% 60% after deducible Preventive care • Well-child services and immu n lzat ions 100% 60% after deductible • Prenatal care 100% 60% after deductible • Routine physicals and eye exams 100% 60% after deductible • Cancer screenings 100% 60% after deductible Lab and X-ray services ,00%; 80% for inpatient services 60% after deductible In-and outpatient hospital services • Facility services(Includes behavioral 80%* :see details below) 60% after deductible health care) • Professional services(includes behavioral 80%* (see derails below) 60% after deductible health care) •mergency care Facility services 100%after $60 copay 1C0% after $60 copay • Professional services 80% 60% after deductible Ambulance services 803' 80% Medical supplies 80% 60%after deductible Therapy services • Chiropractic therapy 80%* (see detaJs below) 60% after deductible no benefits for services from out-of-network providers • Occupational and physical therapy 80% 608% after deductible** (see details below) • Speech therapy 80% 60% after deductible** (see details be/ow) Prescription drugs • 31-day supply,3-cycle supply of oral 80% coverage, member responsible for a 8O% coverage, member responsible for a contraceptives for 3 copays, formulary minim.lrn of $10 and a.maximum of $30 minimum of$10 and a maximum of$30; you drugs only per prescript-on pay the pharmacy and file a claim. In addition to copays,member will be responsible for amounts in excess of the allowed amount. • Ma border drugs(50-day supply) 100%after 540 copay How cost sharing is calculated Copays are flat fees you pay at the time you receive a service. Coinsurance is the percentage of charges you pay for a service its based on the allowed amount. Deductible charges are subtracted from the allowed amount Allowed amount is the negotiated amount that network providers have agreed to accept as full payment at the time your claim s processed if you see a provider who doesn't participate with Blue Cross, the allowed amount is either the billed charge or a percentage of the network allowed amount, whichever is less For highest level of coverage,use Select Network providers for outpatient chiropractic and behavioral health services. For all other services use the Blue Cross Network. .. .'� **Physical,occupational and speech therapy services limited to a 5500 maximum per calendar year j ' his is only an outline of plan ben of's The contract anti ce. f c re nciude complete derails ot vvhat a d!sr,t co'e -u services not covered inciude eyeglasses,hearing aids lens primarily used for a con-medical psir pose,over-she-counter drugsnu. t anal sunolemerts,services rat are cosmetic. 81ueCross BIue$hleld experimental not med-ca.ry necessar,.or co vereo he v:crkers cdmpensabor or no foot auto insurance.Pre-er;Mg condi:ors may nol he covered nor of Minnesota a limited period of lime 'F us nit S reduced by pi or continuous coverage ana doesn't apply to pregnancy newborns adopted children or handicapped dependents See'mature a large network or health care providers.Each provider Is an ndependent contractor ana is not our agent Norpart coating F5906520 19/04) providers do not hate contractswim v Bt„e C'tss ana Biue Shed or Minnesota Blue Cross and Ste Shield or Minnesota is a^i^deciencem licensee ;clan wmbersa tr3 brrci of rite Blun C'oss and Bve Shield Association Benefits ate efeuve Jan 1,2026