5.2 ERMUSR 10-11-2005 - Laserfiche WebLink

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111 u 14, 1 th copay plan Please note.Benefits are subject to regulatory approval •M j .4 S `r ' ' Fi -,: x -i- IN-NETWORK �_, .. K kr ;R „ ,y. T.• . ,,:x.5.1. <' EX7ENDrtD''I.OUT�,O -NE7Vt OR ' inual deductible none $300/person-$900/family Out-of-pocket maximum I $1,500/person 45,000/person A separate out-of-pocket maximum of$500 per person applies to prescription drugs I Lifetime maximum $5 million for services from all providers Office visits or Urgent Care visits • Illness or injury 100%after$15 copay 80% after deductible I • Behavioral health care(mental health, 100%after$15 copay* (see details below) 80%after deductible substance abuse, eating disorders and autism) • Chiropractic manipulation '100%after$15 copay* (see details below) 80% after deductible,no benefits for services from out-of-network providers • In-office surgery/allergy-related servicesI 100% 80%after deductible Preventive care • Well-child services and immunizations 100% 80%after deductible I • Prenatal care 100% 80%after deductible • Routine physicals and eye exams 100% 80%after deductible • Cancer screenings 100% 80%after deductible I Lab and X-ray services 100% 80%after deductible In-and outpatient hospital services • Facility services(includes behavioral 100%* (see details below) 80% after deductible health care) I • Professional services(includes behavioral 100%* (see details below) 80%after deductible health care) Emergency care oOutpatient facility services 100%after$75 copay 100% after$75 copay utpatient professional services 100% 80%after deductible Ambulance services 80% 80% ' Medical supplies 80% 80% Therapy services • Chiropractic therapy 100%after$15 copay* (see details below) 80%after deductible,no benefits for services from out-of-network providers I • Occupational and physical therapy 100%after$15 copay 100%after$15 copay 80%after deductible** (see details below) • Speech therapy 80%after deductible** (see details below) Prescription drugs • 31-day supply,3-cycle supply of oralI $5 generic/$30 formulary brand/ $5 generic/$30 formulary brand/$45 nonformulary contraceptives for 3 copays $45 nonformulary brand brand, you pay the pharmacy and file a claim In addition to copays, member will be responsible for amounts in excess of the allowed amount I • Mail-order drugs(90 day supply) $10 generic/$60 formulary brand/ $90 nonformulary brand IBlueprint for Health programs Employee assistance•stop-smoking program•24-hour nurse advice line•prenatal support included with plan •online wellness center•care support for chronic conditions•fitness discounts How cost sharing is calculated Copays are flat fees you pay at the time you receive a service ICoinsurance is the percentage of charges you pay for a service It's based on the allowed amount Deductible chaiges 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 belied 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. OU **Physical,occupational and speech therapy services limited to a$500 maximum per calendar year This is only an outline of plan benefits The contract and certificate include complete details of what is and isn't covered Services not covered include IMinnesotaoss BlueShield of eyeglasses,hearing aids,items primarily used foi a non-medical purpose,ovei-the-counter diugsinutiitional supplements,services that vie cosmetic, of experimental,not medically necessary,or covered by workers compensation of no-fault auto insurance Pre-existing conditions may not be covered for a limited period of time This limit is reduced by prior continuous coverage and doesn't apply to pregnancy newborns,adopted chiidien or handicapped dependents We feature a large network of health care providers Each provider is an independent contractor and is not our agent Nonpaiticipating F5985R2 t(7/05) providers do not have contracts with Blue Cross and Blue Shield of Minnesota Blue Cross and Blue Shield of Minnesota is an independent licensee 'Man number at of the Blue Cross and Blue Shield Association Benefits are effective Jan 1,2006