3.8. SR 11-15-2004 - Laserfiche WebLink

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CITY OF ELK RIVER COMPREHENSIVE MAJOR MEDICAL Plan 2 TillS IS ONLY A SUMMARY AND IS SUBJECT TO THE TERMS OF THE CONTRACT AnnualOeductibles $500 per person, $1,000 per family Annual Coinsurance Medical- 80% (usually) of allowed amount to an out-of- pocket maximum 01'$2,000 per person; $4,000 per family (includes: deductible, copay, and coinsurance charges.) Prescription Drugs - out-of-pocket maximum 01'$500 per Derson; $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 Davments 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. - Immunizations and vaccinations; Members age 6 and over: 100% no deductible. For - Routine lab and x-ray services nonparticipating providers, deductible then 80% coinsurance. Physici~n Services - Inp~ient lab and x -ray, in hospital Subject to deductible and 80% coinsurance, 100% thereafter. meeJiical visits, surgery, and ane~thesia; - Office visits for illness and injury, Subject to deductible and 80% coinsurance, 100% thereafter outpatient lab and x -ray - Cancer screening 100%, no deductible Other Frofessional Services - Chiropractic Care Subject to deductible and 80% coinsurance, 100% thereafter ($500 maximum benefit per calendar year for nonparticipating providers). Subject to deductible and 80% coinsurance, 100% thereafter. - Home Health Care $25,000 maximum per calendar year. Inpatie~t Hospital Services 365 days of medically necessary care Subject to deductible and 80% coinsurance, 100% thereafter. in an a'<ierage semiprivate room. 11103/04