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1v i t 1t cop ;~ v p 1 ,~ !t ~'easenute:Ba',"+;[,a~,~'~'e~ ;o:^a~.u=r~~~~a,~~l:~„ci+
<br />Annual deductible none $Z00%person-$r00;'falllily
<br />Out-of-F?otket lll8xm7um ~ ~ 1, 100?peron- $S ~l~l~lrf3llllly s 4_.SOOrperson
<br />ASEparatEOUt-Ot-pOckdtnlaXlnlllRl ~1,=110~'p!er=ill-~5,l1Lll+'famlll' i. ~~,5001'perSOrl
<br />of $500 per person ~?r $1, 000 per tanlil~'
<br />applias to prescnption drug=
<br />Lifetime rllaaimulll $5 million far sen'ICes from al l pro~'iders
<br />Office visits or Urgent gar e vi,its
<br />• Illness or injury '100°~b suer 3?O copav or ~ ;-$25 copav ~ t0°,o alter dedudiLle
<br />• Eehavfioral health care lnlental health, 1004~i after $'_0 eopay or ~,~ ~$~5 copav *
<br />~ ~ OS~t after dedudlble
<br />substance abusE, Eatnlg disorLiers uxL-+et~'ls ~I~ovs
<br />and autisllll
<br />• ~hiropradlc nlanlpulation 100°o after :~ ~> $20 copal of .~n~ $~5 copav * ~ 0°n after dedur~lble ; ~~ L», ~ f~~,
<br /> ire ~^?aI_ balaaa ~ r-tes f o;l~ c~,~ ~ trva+-~ 17da•S
<br />• n-pf11CE CLIrQErV`~~BEfC~y-related Sell'ICeS ``;~"~L Ltd"~u BttErdedLlL~Ib12
<br />pr c'.V c'.ntlVC' carE
<br />• 1~1+EI1-child Sefl+lce$ and llllfllLUlIZ3UOlls t lll~°.~L t~~"b after dedULrtlbl2
<br />• Fl Enatal care 100`rL b0°b after deduc~lble
<br />• ~QLltint physicals arld Eye e\3111= I I~~~°,~i, C.S~°.~6 aftEl dedUitlbe
<br />• Latl CEr CC12ell In i7_ ~ 00 `lb ll~".L effel dedLl Bible
<br />La k? and ~-ra\' ?ErVI%eS 1 L~L~`~b; 0"L tL?i IllFiatlEnt Serl!1cE5 L.0°L after dedUCtlL,le
<br />In- and outpatient hospital servieEs
<br />• Facility sen.ices jindudES behal ioral 80".L * isee Bets 1. ~~eloLro;? o0".t after deducrtibla
<br />health carE)
<br />• Professional senlices ~lndudas behatrioral 30°i' icee de ? ~ ',~iev>;? c0°t altar deductible
<br />health care?
<br />En7era2ncv care
<br />• Outpatient facillt~' services I00°6 after $'S copav I00°i after ~'S copav
<br />OLIt(JatlEllt F?ltesslOlla SEn+I~ES till"b l~~"•L aftEl dedLlCtlbE
<br />.ambulance sErvice+ SO"o 80°.t
<br />I~'Ied Ila I $UF?F?I12i ~~~`~L l C~`~L, attC'r lledLlLrtlblE
<br />T ll er ~1F?y SerV Ii.25
<br />• Uhiro?Tactic thera,l
<br />{- (-' 80`~6* ':ee e a l~ bejovl,!
<br />I- 1 , , ~,~;, ` rte.,
<br />ll`~b after dEilU Ertl L.E;
<br /> ~~f7l~~~ .. Ji?? OUi-pi-;'uttrt/i?;~~ P ~01'iiY y'~.
<br />• l~!QUpatlOna and ph)!slca th Er"8pV :Ll°~u ll~`}i 31t2r ~iz~lU dib2~~ l~°e T 47-~'elOVia
<br />• tipeEcll th Erapl' ~l ".'u l l~".'b after dedLl LEI bEt ~ jJ" il'Oi3!!J ~`~'!CVI~;I
<br />Prescription dru~~s- 31-day +upF?ly
<br />• ~-~ydE supph' of oral a?ntracepti~,es for $0 generid$_ 5 formulary brandy $Ogenerivx5 fornlularv brand/x50 nonfonllulan'
<br />~opays $50 nonfonllularybrand brand: n7Erllber paysthE pharnla~y,andtilES adaim
<br /> In addition to cx,pags, I~lernber ~roill be responsible
<br />ft,laintenance prescriptions - ~0-day supph' for amounts m excESS of allowed arllount
<br />• a0dayRx retail nehroork or by rllail ordEr $0 Generic, ~?0 forrllularv brand-+
<br /> $ 1?5 nonforlllulanl L?ran Li
<br />ill ~-Cl'~~ ~ t7 T.V ~ ..1~d .. il~ ? c7 ~,la'?~~11 ~ LJ~ 3 il.~'7cY-•l3 •lL ~Cf '~.1;. 'lL^ IL'tti :1t Y~~ i7 k.9q ~2' it'~'16 X3'7? Y~`L ill d-^2'^L nl^~~ ,.'?7',`L ~'
<br />_ L^L v Ll ;. 1' «. ~~.. ,. ~ I'l ,Jf~L G?tea C~h. G. .
<br />..,,,~i,~,~,Jtho >`i.C1 c0+Y J?',IL i43 RQ'-n:?nt ~'i.V.
<br />Blueprint for Health proararns ErllploveE assistance • stop-smoking program • 2-1-hour nurse advice line • prenatal ~Ippurt
<br />Indudad \rolth plan • onlinE \wEllness center • care support for chronic conditions • fltnes, discounts
<br />HO\~\~ ii?St sll 3f lrl _} IS c3cU3tzd
<br />CO[kiy5 3fe tat }PT ti1111 pay 3t the tl Rle \'OU t2~eIV2 3 sPI'VI~2.
<br />Coinsurance I~ ale f121t211C312 O} il131Q2= VJLI pal' t01' 3 X21 VI~2 . ICS I?3-+2i~ ilrl 1}lP 311;^Y112 t'~ 3nlt L1tlC
<br />fed UCtl~Jle ill3r 125 31 P Lib b a~Ced irOm the 311 ~Ve ~ 3RleLlllt.
<br />Allowed amount Is flip I1270b3ted 3R10Utlt t}l3t ietLtrillk pl ilvl d2r~ have 3gle2d t0 3Ciept 35 }Lill ~: 3Vn1211t 32 the bn1P VJUI 0131 R1 h plOi 2`2 ~ I} VOLI fee 3 }?IOVIi1dl 4M hi? i10 P=n't }?3f 0~I}: 3t? btllto
<br />BLIe Lr0`, dlP 311011+e ~ 3mi?Urli IS 212I1er the billed dl3re7P Jr 3 pPri2nt3 7e i`t dlc' n2MliX li 31114113 i1 3R1 i, tin( 4VhICIIPVPf IS 2i~
<br />For highest level of coverage, use Select !L'etwork provlden for outpak'ent chiroprac6'cand behavioralhealth .cervices.
<br />For ali other services use the Blue Croce Network.
<br />~" ?hy~ical, occupational and spEech therapy :ervicesllmrted to a $500 maximum per calendar year
<br />~. .
<br />brmT• ~,,~ ~1J Thl_ is my 3n outline of plan ben2}i~ The ~onb3ct 3n i ;artiii~ate in line L nlplate detail, of mh3t i. and inn t covered ~2n1 ~ not avared indudr
<br />~,'~' evr_ll3.e., h23nn t 31 ~ Items primarily u.ed for anon-mediLal F Llrpo.e. ol2r Jl2-counter dI Li t nutrltlonal suppl2m2nb- ter\ Ire= tl 73t are c ~meGc
<br />~~~.i2S'~[~TS'~ ~~:lR+~a'fIN~C" e~p2rim2nt31. not medically n2-2~ary. cr covered by elork2n' comp2lraben ;~r no~f3ult auto ir2ur3nc2. Fre-et~bna condlbum may net b2 <evered feI
<br />Oi Allir~fla~a[3 a limited period o(bme Thi_ Ilmit c reduced ly prier continuoLS ccvrra_72 and do2snt 3pph~ to pregnanZ~ neyuborlr, adopted dlildren ar h3ndlcapp2d
<br />d2p2rld2rl~ 1A72 teaRlre 313r ~e Il2LLVJII: ci I1231th L3'2 (:IJYIdel~ E3 ill pli^41d21 IS 3n In d2pelld2110 ~Ollb3il01 3f'd I= nOt OUt 312nt Nullp3l bilp3tlrl7
<br />FS l5~ R?? i=Or1 providers do net have cantracts evnt}l Blue Gam and Blue tihl2ld ai R!linnr.ota. Blue G ~ and Elul shield of NIInn2sota ~ an rnd2pendent licer~2e
<br />iFlan numb2n a 11=. b 1111 0(~e BIu2 Crate and Blue tihi2ld ~~aaation Benefit are atfecOve.'.uly 1, _00
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