5.2 ERMUSR 10-11-2005 - Laserfiche WebLink

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Ii11iiEierS \/ a k i 'J a r�f i I r._t (-1 l "1 with copay plan Please note:Benefits are subject to regulatory approval w:�,. , ,r ..„; :•,,,,,,,71q. :- •`x ,: IN-NETWORK EXTENDED/OUT OF-N SIV, ual deductible none $200/person-$600/family I Out-of-pocket maximum A separate out-of-pocket maximum $ $1,100/person-$5,000/family 0 $2,500/person $1,300/person-$5,000/family 0 42,500/person of$500 per person or$1,000 per family applies to prescription drugs ILifetime maximum $5 million for services from all providers Office visits or Urgent Care visits • Illness or injury 100%after 0$15 copay or 0$25 copay * 60%after deductible I • Behavioral health care(mental health, 100%after 0$15 copay or 0$25 copay* 60%after deductible substance abuse,eating disorders (see derails below) and autism) • Chiropractic manipulation 100%after 0$15 copay or 0$25 copay * 60%after deductible,no benefits for • (see details below) services from out-of-network providers In-office surgery/allergy-related services 80% 60%after deductible Preventive care I • Well-child services and immunizations 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 IILab and X-ray services 100%,80% for inpatient services 60%after deductible In-and outpatient hospital services • Facility services(includes behavioral 80%*(sec details below) 60%after deductible health care) I • Professional services(includes behavioral 80%*(see details below) 60%after deductible health care) Emergency care outpatient facility services utpatient professional services 100%after$75 copay 100% after$75 copay 80% 60%after deductible Ambulance services 80% 80% Medical suppliesI 80% 60%after deductible Therapy services • Chiropractic therapy 80%*(see details below) 60%after deductible,no benefits for services from out-of-network providers • Occupational and physical therapyI 80% 60%after deductible**(see details below) • Speech therapy 80% 60%after deductible**(see details below) Prescription drugs • 31-day supply,3-cycle supply of oral I contraceptives for 3 copays $5 genenc/$30 formulary brand/ $5 generic/$30 formulary brand/$45 nonformulary $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 • Mail-order drugs(90-day supply)I $10 genenc/$60 formulary brand/ $90 nonformulary brand BluePnnt 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 I 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 It's based on the allowed amount Deductible charges are subtracted from the allowed amount IAllowed 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 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. I **Physical,occupational and speech therapy services limited to a 5500 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 I1111° eyeglasses,hearing aids,items primarily used for a non-med cal purpose,over-the-counter drugs/nutntional supplements,services that are cosmetic, BlueCross BlueShleld experimental,not medically necessary,or covered by workers compensation or no-fault auto insurance Pre-existing conditions may not be covered for of Minnesota a limited period of time This limit is reduced by prior continuous coverage and doesn t apply to pregnancy newborns,adopted children or handicapped dependents We feature a large network of health care providers Earls provider is an independent contractor and is not our agent Nonparticipating F59B6R21 (7/05) providers do not have contracts with Blue Cross and Blue Shield of Minnesota Blue Cross and Blue Shield of Minnesota rs an independent licensee I (Plan numbers a 113 b 114) of the Blue Cross and Biue Shield Association Benefits are effective Jan 1,2006