5.3. ERMUSR 10-09-2007 - Laserfiche WebLink

Home Browse Search

- ! ' ` t ~ ', `' " , } + " r ~ ' Please note• Benefits are sub rt to r laic a roaal le- ~ ry Pf~ Ealendar year deductible None ~3001petson - ~9~Glfarrrily. Out-of-pocket maximum ~1,5001person $5,040,rperson A separate out-cif-pocket maximum of X500 per persor, nr g1.00G per famil;~ applies to prescription dnags. lifetime maximum ~5 million far ;erJicesfram aiLpcovlders Office visits or urgent care visits • iline;`~ or injury, 1 GGoiQ after $2G ccpay 8G% after deductible • Behavioral heaBl-~ car? (mental h?atti-~, 1009'o after $20 copay` (seV details below) 80% after deductible sub;rtanc? aGtlse. eating diu~rders and autism) ` • Chiropractic manlp,~ation t OG96 after $~G Copay* (see details below) 8G% after deductible; no benefits for services irorn our-of-network providers ' • In-office surger,<,+allenpy-relat?d serrlces 100% EO% after deductible Preventive care • +N?If-child sen:ices and Irrrmunizatiors 1 GG% ' E04'o afiter deductible • Prenatal care 30046. 80% aftef deductible • Foimne physicals and eye ?xarns 3 0©% ` EO96. after deductible • Cancer sQeenir~gs 1G0%' 804ti after deductible Lab services 3Ot?%: 8646 after deductible X-ray and diagnostic imaging 30tT% $0% after deductible in- and outpati err[ haspitai services • Fadlity services ¢ndudes behavioral health care) .100%* .L,ee derails br-3ew) 80% after dedurtible • Professional services (irdudes behavioral health cjre) 1 G096* fs~ details b°lowi EOgS after deductible. Emergency care • Outpatient fa~lR~f seraices (0046 after. X75 clay t 00ao after $75 copay • Outpatient professional services 300% 8046 after deductible Ambulance services 80% 80°~6 - Medicat supplies EG% 80°,6 _ Therapy services • Chiropractic therapy 100% meter b20cop~ay* ~ e¢de~i~ belani7 8Q% after deductible; no bartefrisforservices ` from aut-of-netvveyrK providers _ • Occupational and playrsral thera~iy 100% after S20 ~_~pay E0~ after deductible** (see det~ifs below) • Speech therapy 1 G0% after S~0 cooay 80% after dedrJCfible** (see dEtails below) Prescription drugs - 31-daY s~PiY _~ • 3-cycle supply of oral cantraceptives far $(} genericR* *f~35 fc~rrnuiary Grand/ ~0 generic***/b35 formulary brand/ 3copays X50 non-fcrtmtiaryGrand 550 norrfarm~iary brar~i; member pays tt"e pharmacy and files a daim. (n addition to capays, member will be ie~,onsible for amounts in excess of aRr)wed amount Maintenance presviptions - 90-day suPPtY • 90dayR:cretail netvuork or ~y mail-order $Q generic"*l57E}focmutaryGrand/ $1~5 norr-famnutaty brand if a generic dr.~g;s atraifable and m>'mberchooses abrand-,name drub merrdiet pays Eire d,Tfercnce between ff,e G,~and .narrre prce and the genr_>rrc price plus any , catnsurance. (n some cases, this can arreunt to the full cost of the brand-nar*le drug.: BluePrintfor Health programs 'Employee asststarxe +stop-smdctng program • 24-hour nur~ advice 6ne • prenatal wpport included with plan ~ onGi-"e wellness cpnte[ rare support for dironic corditirns • mness r~scnunt, How cost Sharing is calculated , Copays aro Flat fees you pay at the time •rou receive aservice: - Coinsurance is th e percentage of diarges you pay for a service. It's based on the a!farred amount. Dxluctibie is the Portion cf the alla.Hed amountyou must pay: Allowed amount is the negotiated amount that network prodders have agreed to acwpt as full payment at the time yon claim is processed: Ifyut sey a prarider who doesn't participa to vrith Blue Cross, the allowed amount is either the 6iI{ed cfrarge or a percentage of the rietvvark allowed amount, +,vbchever is less. * For highest level of cvv~age ore Select network providers for outpatient chiropraQic and behavioral heaftb servit~s For al! other services use the Blue Cross ne~tworfc y;=.~~t `* Physical occupational and speech therapy services limited to a 5500 maximum per ralencfar year ~ ~ *'* SO mpay to member, rnsi of generics ihduded in premium or daims cost rni~ ~ only an outline of p{~n beneFfts lY~e cor~trxt and certiFiiate Irxlude ccm>fete decals of •what s ar~d ~n't «~wred. Ser,ces nc~t coffered include eyeglasses, hear a~g ~~u~~`~~~~~`~=N`~R~^=~?~ aids,ilerresprin~rityu~xdforaran-medkalpuepo~,over-the-ccunterdnagshrutrltionalsupp~ments,serv'r_esttratarecosmelic,experimental,riolmedkallynxessary,a i i373~3a~+'~~ covered t~yvvrr:ors' compensaticm a no-fault auto ir~surarKe. P~e~r<iA~q conditFx~s may not be caPred for a firmed periai of Urtx Ths IFnit is reduced bf prior continuous (Plan numtr_r4) coverane and doesn't applyto pegr"ancy, nev~txxra, ark~p(ed ctddrer, Gr handkapped dependents. We feature a large neNnorkf,( FKalihcare povidets Ezr_h provider s an ind?Fendentconttdtorand is notour agent. t~kinpartkiptkng providers do not havecor"trct,vrtth Blue Crvsand Blue Shield of M1Ainrrsota. Bk,e Crosand Blue ~'iiu!d FS925R23!3lG~ d P.latnesota iron independent licensee cf th=_ Blrw CrcFSarrd Blue Shield ti~~xiar.pn. Benefitsareeffectrs luy t, 2Ga7.