5.2 ERMUSR 10-11-2005 - Laserfiche WebLink

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Iti_ 'i ! P i i ln [ ! Ii w i t I1 d e d u C t 1 b I C plan Please note:Benefits are subject to regulatory approval +,�S r i v ° c. ri,in.�; ' .. 'fit., x - .-- " rY !1t aYtrisa^te: .x ;;�r-,f.�;;=.,. -4''''-'7z‘,--... 4, IN-NETWORK EXTENDED./OUT-OF�NET IV,ORK' nual deductible options 0 $ 300/person-$ 900/family ployers choose one of four options IOne deductible applies to services from all providers Out-of-pocket maximum Q 51,500/person-$5,000/family Q $2,500/person These options correspond to the deductible Iselected A separate out-of-pocket maximum of$500 per person or$1,000 per family for prescription drugs ILifetime maximum $5 million for services from all providers Office visits or Urgent Care visits • Illness or injury 100%after OQ$25 copay 60% after deductible • Behavioral health care(mental health, 100% after 00 525 copay 60%after deductible Isubstance abuse,eating disorders and autism) * (see details below) • Chiropractic manipulation 100%after 00$25 copay 60%after deductible,no benefits for *(see details below) services from out-of-network provider • In-office surgery/allergy-related services 80%after deductible 60%after deductible IPreventive care • Well-child services and immunizations 100% 60%after deductible • Prenatal care 100% 60%after deductible • Routine physicals and eye exams I 100% 60%after deductible • Cancer screenings 100% 60%after deductible Lab and X-ray services 100%,80%after deductible for inpatient services 60%after deductible In-and outpatient hospital services I • Facility services(includes behavioral 80%after deductible*(see details below) 60%after deductible health care) • Professional services(includes behavioral 80% after deductible*(see details below) 60% after deductible lithealth care) rgency care • Outpatient facility services 100% after$75 copay 100%after$75 copay • Outpatient professional services 80%after deductible 60%after deductible Ambulance services 80% 80% Medical supplies 80%after deductible 60%after deductible Therapy services I • Chiropractic therapy 80%after deductible* (see details below) 60%after deductible,no benefits for services from out-of-network providers • Occupational and physical therapy 80%after deductible 60%after deductible** (see details below) • Speech therapy 80%after deductible 60% after deductible** (see details below) IPrescription drugs • 31-day supply,3-cycle supply of oral $5 generic/$30 formulary brand/ 55 generic/$30 formulary brand/$45 non- contraceptives for 3 copays $45 nonformulary brand formulary brand,you pay the pharmacy I 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) 510 generic/$60 formulary brand/ $90 nonformulary brand 'Blueprint 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 111 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 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 billed charge or a percentage of the netwoi k 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. ® **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 IueCross BlueShleld eyeglasses,hearing aids,items primarily used for a non-medical purpose,over-the-counter drugs/nutritional supplements,services that are cosmetic, ■f Minnesota experimental,not medically necessary,or covered by workers'compensation or no-fault auto insurance Pre-existing conditions may not be coveied for a limited period of time This limit is reduced by poor continuous coverage and doesn't apply to pregnancy,newborns,adopted children or handicapped dependents We feature a large network of health care providers Each provider is an independent contractor and is not our agent Nonparticipating 17097P07 17/05) providers do not have contracts with Blue Cross and Blue Shield of Minnesota Blue Cross and Blue Shield of Minnesota is an independent licensee 'Plan numbers a 118 b 120 c 122 d i23) of the Blue Cross and Blue Shield Association Benefits are effective Jan 1,2006