4.1. SR 11-27-2000 - Laserfiche WebLink

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FROM : MINNESOTR INSURRNCE PHONE NO. Partial listing at COld Services -, In-Network Benefits These benefits apply when services are provided by network providers or lor services authorized in advance by Medica Health Plans. When you receive covered services after deductible has been satisfied, Medica Health Plans PAYS: U!J ii' ;1 31-day .~uppLy for medit..'auoru n:c:fti~d ac a nCDWOTk ph:LTTI1I1CY. 100% after $11 copayment per pre- scription or refill for medi- cations dispensed according to Medica's formulary. The deductible.cloes not apply. 100% after a $26 co payment per pre- scriptlQn or refill for medications not on Medica's formulary. The'deductible does not apply. ('..tall mUSt be provi&d by a Mu1i=<.lesignau:d mcmral hedch prO'llider. IOU mUSl receive auth.:)ri~ from M..dU-.as d.esip;rlLlretl mental ~aM: prooid....,. {lliCJf' ra reci!lumg SG"l'viCdS. 100% after 20% coinsurance for individual therapy or 1 Q'l/o coinsurance for group therapy. The deductible does not apply. 80%. PRESCRIPTION MEDICATIONS RECEIVED AT A PHARMACY MENTAL HEALTH CARE · Outpatient services · Inpatient services ~ABUSE CARE . Care mtcSl be providd by a Medic;~.;ignaletl ~ubsratlCc abu.s;: prouider, YOk mL<.~r receiue aurllCrb:l.rian fr(1m.1v1edica 's i:k~ignared sub- S1aI'1Ll: ~e pro~ider prior to receiving $ervices. 100% after 20% coinsurance for individual therapy or 10% coinsurance tor group therapy. The deductible does not apply. 80%. · Outpatient services · Inpatient services fHABJllTATIVE THERAPY RECEIVED IlllE PROVIDERS OFFICE OR HOSPITAL · Pbys\cal Ulerapy · Occupational therapy · Speech therapy URABLE MEDICAL EQUIPMENT 80%. 80%_ 80%. 80%. 763781217927 Nov. 17 2121121121 11:24RM P2 Out-ot-Network Benefits** These benefits apply when services are provided by non-network providers. When you receive covered services after deductible has been satisfied Medica Insurance Company PAYS:' LJ /J !ll a J 1 :dt.lJI .~t<ppLy fen mc:d.ic:arior~ TE:c:eiVI'.t1 al" T1on-1lIUUr01lc pJw.TmIJi.::y. 60%~ Member pays the greater of 40% or a $26 copayment. 70%: 70%~ limited to 120 days per member. per calendar year for all inpatient services cOlT1bined. 70% ~ 70%7 Limited to 120 days per ' member, per calendar year for all inpatient services combined. 700/0~ 70%~ 70%~ 70% ~ HlROPRACTIC CARE 80%_ 70%~ Limited to 15 visits per member. per calendar year. Jverage is limited to the non-network provider reimbursement amount (as defined in your Certificate of Coverage) after ~ductible is met. . you decide to utilize your Out-of-Network Benefits, you may pay more than you would for In-Network Benefits. 1e amount you pay coultl include a percentage coinsurance, a fixed dollar copayment and/or deductible amounts. In ldition. if the amount that your non-network provider bills you is more than the non-network provider reimbursement nourTt (as defined in your Certificate of Coverage), you are responsible for paying the difference, and such difference ill not be applied toward the Out-of-Pocket Maximum. . . \'t; THIS HEALTH CARE PWI MAY NOT COVER ALL TOUR IlEiLTH CAR. ExpeNses; REAIl YOUR CONTRACT CAIlEFULLY TO OmRMlNE WHICH EXPENses ARE COVERED. s is 3 bene/II summary only. and doe; nal oulline all QI YOIII DanelllS. WRen you enroll wUh Medica InsuraRce Company (MIC1, you will fICeiv. a CallhJ...le 01 CoveraPI. Ie" is a discrepancy petween Inlnrmatian in Ibis 5ummarv and your Cellilleale 01 Coverage, Tile Certlli~le .f CoveraQe will taka prac:adence in determininQ your ~enellls. Ila.c1 ClIstalller SalVlea el ~Z.g45-8DDD (Mpl!./SI. P'auJ metro ~rea). 952-992.3190 (MPIs./SI. Paul malro 3lIa memoers wilh hl..ina imaeirments). 800-952-3456 (oulsial .PIS'/~I. !';Jut metro areal. or 8Oo-a41.Gl53 (oulslde of Mpla.lSt. hul melro area lIIembc~ "ilh hlaring imoaillR8IIliJ lor more IlIIlllmaJion III' a/I$W81S fa speellle quesUaos.