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1'h 1 ~- ( 1 id l' it 11~ l4 t '1 L~ !~ C; ~ !- f~ ll >7(0d Cenote:Be'?e+l's ar~si'iPed 20 "~1'Ti.ll?'vl~'1•?C'q,iJ 1':3?
<br />~,nnualdeduaik~leoptions ~ =OOrper son-$ 900~family
<br />Employers choosz onz of four options $ 500%pzr son - $ 1.000+'fanllh
<br />One dzdudlblz applizsto sen,lczs from ~1 0001; pzr ;on - 32,OOOOfanllly
<br />all pro~~iders $?,000lper son - $4 000+'falllily
<br />O Ut-C~t-pOCI:et nI~XIIIIUl11 ~~,f $ 1,500)pefsOn -$S,OOOrfafllllV $~,5L1 L}1per50n
<br />Theseeptionscorrz=pond tothzdzductible $1,800ipzrson-$S,000farlldy $~,-OOr'person
<br />selz~zd .4 szparatz out-of-pocket rlla~nlnnn r $2.2501pzrsc~n-$S,OOOr`farlldy $2,'OOipzrson
<br />of $500 perpzrson or $1,000 pzr falllilyfor ~ $~,SOOlperson -$S,000ifanlily ~~ $=;000ipzrson
<br />przsaiption dru~Ts
<br />Lifetnlle nuaxinulrll $5 Ilvlhon for szn+l~zs from 311 provldzn
<br />Off,ce visits or l!raent Care visits
<br />~
<br />• IIInzSS or inlur~, I00°b attel r o ~ :~ $~5 copay ,I i ~= L co pay 009b after dedudlblz
<br />• Ezhavloral health cart (nlzntal hzalth, 100"6 attzl 4*dy,P $?S a~pay of ~ ~.: $0 a~ pay r0`~6 aftzr dzduc~lblz
<br />ubstance abusz, zavng disorders and autisnll * r 7etall~ I ~ioat~l
<br />' ChIrOplaCtlc RIanIF, Ll atl ~~n 1111}". altel t..t ~,y>r $~ S cOpay OI e~ e:,,W $= ~ cO pa4' L 0°6 aftel ded Ll c~lb O L~8 °' iJ !0•
<br /> t ~ 7Pi371} 4ie Qll ~ ~ 1,.~~~ i~-, ui-~ , .Jrll'i. J); ~ ~1". iY ~.
<br />' n-ottlcz Slll~}z11'±32fC}~'-r2 3tc. C1 SctIIIC2ti ~ l~".ro 3ftzr dzClUCrtlk~2 l l}".~b 3ftPr X12 Ci ll CflLiz
<br />pf eV entlve %a r2
<br />• 1'vell-child senliczs and irllllluni~ations 1 004ro u0°6 after dedudlblz
<br />• Prenatal cart I u04-b 609 after dzductiblz
<br />• Routinz physicals and zye zxanu 100".o r0`~,t after dedu~rtlblz
<br />• lan~c'f SQ"zznln C}5 1lll~"~l 111 °.~L 3ttc'I liZ Ci ll Ctlk?2
<br />Lab and X-ray services 100:1, 4001 after dzdu~~lble for lnpatiznt senliczs 00°6 after dzduc~iblz
<br />In-and outpatient hospital services
<br />• Fazilit>' szn,lcestindude; behavioral SO"6 aftzr dzduc~tiblzt fcee o~`all~ revl? 0006 after dzduc~lblz
<br />health carzl
<br />' ProfeS'IQll al SeR+ICeS ~I Il CLldes bzh a\AOl"a :~l}°6 aftaf dedUdlbe~ (~-.~ d?f3 ?l~,V1 ;? ll~"6 aftel dedLl ~tlb2
<br />health cart?
<br />E rll el'Qe~rI CV Cale
<br />• OUtL,3tic'nt fall lt\•~ tizlV Ices 101"o aft of $S iOL,a1' 1l}l}`~~b after $~S ~Op31'
<br />• OLltp8t12nt prOfZ55iOrla 52r~rIC05 tiQ~~u afteF dzdLldlbe r0°~o fitter dedLlctlbe
<br />Alllk?u genie S2rvlicS 80`0 0°.i
<br />Medical supF?Ilzs SO".o after dzdu~~iL,lz e0`~6 after d2dudlblz
<br />Therapy services
<br />• Lhl lrOpra Cell thelap\' l}`~~L 3ft21 i?2li l1 C~IL,z l - cYF.'3 l?!Ol'I~',~ ~l~oL ~1t21 d2 dLl ~~lk,c. •~. ~?:3'~ -.
<br /> ~efly~g$'. Ji?7 it ~~~-~~ -,•°i14~'i~iY L?I~O VJiY ~;S
<br />' OccLl patlJll a and phi\51Ca therap)+ 80°ro after dzdudlba l5ll ".~l 8ftdr dzdu ctlbz~~ kSee Y. 91~ ~o1Cl VV?
<br />• ~F'?eech thl er"ap\' l}u.L 3ft21 ~1211U~-(IL,z l l}uL dtt2r 112dU C~ILIIz.'~ l~'? i7?i31i} ~~af~~~:~.1
<br />Prescription drugs
<br />• I -day suppy; -q de supply of oral 35 aznzriv$=0 fonllulaly brand+' ~5 aenerici$0 forrllularv brand?$-15 non-
<br />contraceptivzs for _ copays $~S nonforrluilan brand fornlularybrand; you paythz pharmacy
<br /> and file a dainl In addition to elpays,
<br /> nlzlllber Arai ba rzspomibe for arllaunts in
<br /> esczss of the allo\nrzd amount.
<br />• ~Isil-ordzr drugs (90-day supply? ~ 10 aenznc,'$o0 formulary brand+'
<br /> `~ ~O II OIIfOnlILIal1' bl 311 Ci
<br />FluePrint ter Health programs Enlplovee assistance • fop-sllmkiny program • ZA-hour nursz advicz Ilne' prznatal ylpport
<br />mdudzd with plan ' online lvzllnzss cznter • csrz alpport for chronic conditions • fitrless discounts
<br />Hovv cost sharing is calculated
<br />Colxays are flat fe25 you pay at the trine you 12ceiv2 a service
<br />Coinsurance i. tfl2 F: ercentag2 of charges you pay for a service. It' k:~ed on the all caved amount
<br />Deductible charges are Subtract2l from the alloex2d amount
<br />Allowed amount is the tie QOtr3ted 3R1JUIlt dl3C n2ibVi?rk prt VId215 haV2 31rePd fo 3ii2pt 35 tUhl p3V Rlent 32 Ch2 trRle l~OUr c131 Rt K ploi2= 2d It VJU 522 3 pf iiVlder V1. ho d1~2_li t p3ltrclp3C2 btilth
<br />Bllle LIOti, dl2 3Vlowed 3nlOUnt IS elChlPl 2112 kllh2d ~Ilar 12 Ot 3 p2rC2nt3ge JI tll2 Il2tbVOI ~ 311ow2d 3R1~~LRl( btihllih2v2r IS he5s.
<br />* Forhlghe~~t level of coverage, u.~ Select Network providers for outpatient o4iropradicand behavioral health .cervices.
<br />For al! other services uce the Blue Go` Network.
<br />Imo' ~ * Physical, occupations! and spe>edl therapy cervices limited to a $300 maximum per calendar year
<br />°~, ~ This c ,nhr an outline .1 plan beneht<_ The conhact and cel trfieate indud2 complete details of what Is and i_n't cov212d ti211aC23 not rover2d indud2
<br />~~U•~~9e.*'~ ~~~~~~ 2yegla~25 heanng al i. it2m< pl lmarif, Lie 1 hr a n n m2dieal F urF~~e .21 tl,2 count2l dlu ~'nuUitronal uFpl2m2nts 2ni es dlat are ~m2trc
<br />~~ ~~~~ 2zpenmental not medicahll n2 e~ary r ~orel2d kvv+ rl,2rs ~omp2r2ati n , na fault auto 1n5urance Ple 211 Un7 coniib n may rnt b2 cav212d for
<br />a limited penod of time. Th1 limit G 12du e 1 ly pnor ~ontlnuolc X0v21 sae ani don't apphl to pregnanvv neeibonr, adopted children or handicapped
<br />d2p2n92nLt ll 2 12aRlre a lar~l2 netwolk of healtll -are providers Eadl pl nd2r is 3n independent contradc I an-1 is not our agent Nanpartiopating
<br />F?0~?R?' (?,O S? pr oalder. da not have co ntrac5 evith Blue i.l Ts and Elul ~hi2d of R'linn2.ota. Elul ~m~ and BIu2 tihi2ld ai Rllnn TOta is an nld2p2nd2nt Ir21„ee
<br />kPt3r, num[en a 115. b 120. c 12?. d 12.1 of the BIu2 Ga` and Blue 5h121d :LSOCia[ion. Benetit< ale eifxw2 Ian 1 200
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