3.8. SR 11-15-2004 - Laserfiche WebLink

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CITY OF ELK RIVER COMPREHENSIVE MAJOR MEDICAL WITH COP A Y Plan 1 THIS IS ONLY A SUMMARY AND IS SUBJECT TO THE TERlYIS OF THE CONTRACT Annual Deductibles None Annual Coinsurance Medical - 80% (usually) of allowed amount to an out-of- pocket maximum of$I,200 per person; $3,600 per family (includes: deductible, copay, and coinsurance charges.) Prescription Drugs - out-of-pocket maximum of$500 per person; $750 per family. Benefit Payment Levels Payment for Participating Network providers as described. If nonparticipating provider services are covered, you are responsible for the difference between the billed charges and allowed amount. Most payments are based on allowed amount. Preventive Care - Routine physicals and office visits; Members under age 6, prenatal care, and cancer screening: - Well-child care, Prenatal care; 100% no deductible. For nonparticipating providers, deductible - Routine hearing and vision exams; then 80% coinsurance. - Imrrtunizations and vaccinations; Members age 6 and over: 100% no deductible. For - Routine lab and x-ray services nonparticipating providers, deductible then 80% coinsurance. Physician Services - Inpatient lab and x -ray, in hospital Subject to deductible and 80% coinsurance, 100% thereafter. medical visits, surgery, and ane$thesia; - Office visits for illness and injury, 100% after $15 office visit copay outpatient lab and x-ray - Cancer screening 100%. no deductible Other Professional Services - Chiropractic Care 100% after $15 office visit copay including lab and x-ray. All other services subject to deductible and 80% coinsurance, 100% thereafter ($500 maximum benefit per calendar year for nonparticipating providers). - Home Health Care Subject to deductible and 80% coinsurance, 100% thereafter. $25.000 maximum per calendar year. Inpatient Hospital Services 365 days of medically necessary care Subject to deductible and 80% coinsurance, 100% thereafter. in an average semiprivate room. 11/03/04