5.4. ERMUSR 10-10-2006 - Laserfiche WebLink

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14' 1 f ~I i= t? ~ r1 }' ~? i tt !I Please note: r"a'?efir~?:~=u~y~ad t\? :^3~t,da'a'1 ?,?,\: ~,l,ij Annual deductible none x_ 00+'parson - $900+'fan7ily Out-of-pocket ma~nnun7 $1, SOOiperson $S,000lpersun 4 separate out of-Pocket maximum of $500 per pesos or $1,000 per tamil~ applies 10 pre SCllpt1011 drLl Q~ klfatltlle RIBYInIUnI `~S nlllO~l fOr SBfVICe. frOlll 311 prOl'Ide15 Offlia VIS Its Or ill gent Lc71C VISItS • Illness or injury 100"o after X20 copay SO°~o after deductible • Behavnora health care (mental health, 100°~b atter $20 eopay~ i~ea m ~.+~ bal~)w~' 80Sro after deductible substance abuse. e3tincY disorders and autisml • Lhll-Op ra ~~IC 17lanlPUatlOn I1~~"L after x'17 0.np ~1'* I~Oe 7. 3!S 1)elOln;=I kl~o,U after dedU ctl k~ e; ,'70 b c fOi ~ ~ , S orb rC~J i~~)i?? ii:~-~.i-:, °i4Vpri; ~ Oyc7erS • In-office surges^•'allerav-related selti~lces 1004~o SOni~ after dedudlLle Preventive earn • 1rl~e-cI71d Sarl+ilt'S and IlYllllLin1~3t10n5 ~ 1717"~L Sly°~L 3ftel dedlll~lbe • Prenatal care 1011°:0 ~0".i after deducrtible • RoUUne physicals and e1'e a\anll I1~1~`~b til~`)ro after dPdLI CtI bP • <_3llcal SCrZZI7111Q5 I1704~b X17°ro 8ttel dedLldlbe Lab and X-ray san~ Ices 100°-b 8056 after deductible In- and outpatient hospital services • Facility services iindudes behavioral 100"{ * i'~ee ae~ ~, k, lovr;? 80°i after deductible health care? • Professional services (includes behavioral 100"ot j's r ",au's k ievl;! SO Si after deductible health caret EI?iaraanc~ Tara • l~Ut~?dti2nt fall it\•' SL•IV IOc.= I l~l~o after" $-S ~Opa~~ 11717 o~t 3ftZC $~S ~Op3~` • l~utpatient professional services 100 u.5 SO St after deductlLle ,4mbu lama sarv Ices 0°6 SO4i ~:'ledlccel supplies SO4~u 80°~i, Therap\' serv leas • L_hlrOpradlc th er3pl' 100°~L aftal X00 cOp 91t I~°' c7. a ~S Jd1i~Vl! SO 4b after dedll ctl be, 1'O ~?8!' J ~tbri..j '~ Ji?? C ~~i-~.r-, ~ °tbVOiY L i)Y? T~rS • OccU paUOn d and ph1'slCa theca py 1171~`~~ti d1YPl $20 cOp34' ~l~°0 3fler i~2dll ctl bleu i=)?"~' Y. 8~h k?: !i)L9~'I • SpeeclY therapy 1170 `'L after ~~17 cOp31' SO"L after declll Crtl b.e*; j'S'Z YP. a'lt belOVl~;I Prescription drugs-?1 -dsy supph~ • -~~'de supply of oral oontraoepti\resfcr $0 aanenc'~= 5 fom?Mary brand+' ~0 aaneri~r'f=5furmular~• brandr~50 nonfomnllar~~ copaYS $50 nonformulary brand br3nd~ member pa4s the pharmacy and tile, a Balm. Ill ai"1d1110r7 tip cOp31'S, rYYalllbc'YLVI k~e lespO~lslba (1:1alnta178 r7ce preS%r IptIOI7S - ~l)-d a4' yU~.?F)1' fOr" 31ll OLl tits In ZYOc'SS Of aObV2d 3nlOllllt. • ?OdayRx retell nehroork or by mail order $0 generic/$?0 formulate` brand: $ I ~ 5 nonformulaly brand ifd ~,9L: ~i1T.l: . \,i 1: i1~.. 'ti4 ^L'~~Il. hL.O`±.?~~2'llti''1:'~L ~~TA:.'T L9,~'C1:/~C:Ilcll*.~'i~~~L 7:L~9'?2:11~3'~i7-'1 l-?.1^ 1~..'~d C~~L CI'L .1~~C'`?i.1 '. _1'Cl .~i .. .~~.!, _t'?ti'Od'~~C:h^G. ..~..~i.~., ,J f,'t fi: ~I~~ i~^S! OI ;~ 5:~7?~7-71: fJt ~Y2.C:. 61uaFr int for Health pro~Prams Employee assistance • stop-smoking prograr77 • ~~-hour nurse advice line • prenatal alppolrt Included lroith plan • onlinevvellness center • care support for chro nic condrtlons • fitne~ discount Ho\n~ ecst shdrin4 is cskulated CO(kiy5 dre 1130 f2p51OU tdV aL Yhp bR1p Vc~LI reCelti2 d Sefvic2 t.ofnSUCanCe L Ch2 pprC2nC3lp o1 clldlge5 vOLI ~.:3V tJl d 521VICP. ICs I?. dsed Jn Cllp dlloeV2d dmOUnC. t)edUCtl ~le ~Il3r l2= d12 5Uk CI3 c22d frORl the 311 ~t~pd 3R10UI?C. Allowed amount IS flip 1121i,43C2~ aRl JLlllt t~ldC netvv i?rk 1:ri,Vli~2 r5 I1 34~2 3]rp2i~ LO 3CC2F t d5 CLlll 1,31 R1Pnt dC CIl2 LIR1P yOLlr IIdIRI I~ ~ I~,C2=52 t1 11 1~OL1522 3 I?I O1~I ~Pr ~Vll t~ i1 i~2511 2 Fdf biIP3C2 4Rrltll BLIe Cr'ow', flip 311 ~)4tlpd 3n10U n215 21th2r flip billed CllafQe i,r d p?I~2n Cdg2 01 the rip t4ti i~r l; doNl2d aRlOLlII C, Yt+lllch 2Ver IS p\ For highe~7 level of coverage, uce Select Network provides for outpatient chiropractic and behavioral health .cervices. For a!! other services use the Blue Cro` Network. ` f`~-°~;~ 't Phydcal, occupational and spc~ch Urerapyservic~s?united to a 8300 maximum per calendar yEar Yit ~~ This Is only do outline of plan l2nehC The conitdct dnd c2r tillcate Indud2 complete detdlls of ~vhdt a and isn't a~v2red. 52nnc2_ not covered in lode ~U!l~JJ53~$itl~*,~fi~*#~ e~~2~la`2shearin~dl~it2m5primarih~us2dioranon-m2di~alturpese,o\21-the-counterdrLr<ti~nuUitl.~ndlSUpplemen~ser~~i.PStf~d[dre~~m2ti` <7~ ~I(1f`I@~C€~~ exp2rim2ntal not medically ne-2s`dry or covered bs ',~oll:er_.' cemperzation or no-1aLJt auto Irzurdnlp Bre-21~ona conditions mdse not he covertd }or d limited period of time This limit ~ redu~2d by pnor eonOnuaLC cov2ra~p and doesi t dpph~ R~ pre~ndnv n2evborrz, adopted children or handlcdpp2d dppend2nts 1A+'e t2ahlre a large n2l4t+erk ~f h2ait!) care plaviders Each praaider Is an indep2ndpnt a~nUactor dnd is not our dClpnt Nanpdrbcipatina F5ge5~? t:0t? prwlder~ do not hdv2 contra.C v+rith Blue Croce and Biu2 Shield of Nlinn25ota. Blue G ~ and Elul ~hipld e(h'llnnesota ~ an Ind 2p2ndent hcert2e (etas numter4? of die Blue Qo and But Shield +hxiation. E2n2hLs are p112e0vp luh~ 1 ?OOo.