6.1. ERMUSR 10-13-2009 - Laserfiche WebLink

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Comprehensive major medical with copay plan Please note: Benefits are subiect to reaulatorvaooroval Pia~fi~ghUgF~tJ~ ~ ~ " - ~ ~''- Extended/out of network - - Calendar-year deductible None 2200/person - $6001famity Out of-pocket maximum 61,100/person - ES,000tfamily $2,500lperson A separate out of pocket maximum of 5750 per person or 51,500 per family applies to prescr(ption drags. Ufetime maximum $5 million for seMces from all providers Physician services • Offke a urgent care visits for illness tx injury 100% after S25 copay 60% after deductible • Retail health dink 100% 60% after deductible • Behavioral health care (marital heahfl, wbstance t00% after S25 copay* 60% after deductible abuse, eating disorders and autism) Chiropractic manipulation 100% after $25 copay` 60% after deductible; no benefits for services from out-of-network providers • In-0fflce wrgery/allergy-related services 80% 60% after deductible Preventive care • Weq-child services and Immunizations 100% 60% after deductible • Prenatal care 100% 60% after deductible « Routine physicals and eye exams 100% 60°/a after deductible • Cancer screenings 100% 60% after deductible Lab services 100%; 80% for inpatient services 60% after deductible X-ray and diagnostic imaging 100%; 80% for inpatient services 60% after deductible In- and outpatient hospital services • Faality services (includes behavioral health care) 80%* 60% after deductible • Professional services (includes behavioral heahh care) 80%* 60% after deductible Emergency care • Outpatient fadlity services 100% after 375 copay 100% after S75 copay • Outpatient profes~onal services 80% g0% Ambulance services 80% gp°~ Medical supplies 80% 60% after deductible Therapy services - • Chiropractic therapy 80%* 60% after deductible; no benefits forservices from out-of-network providers • Occupational and physical therapy 80% 60% after deductible*' • Speech therapy 80% 60% after deductible"" Prescription drugs • Retail (31-day supply) S5 generid535 formulary brand S5 generidS35 formulary brand S85 non-formulary brand S85 non-formulary brand; member pays the pharmacy and files a claim. In addition to copays, member will be responsible for amounts in excess of allowed amount. • 90dayRx (90-day wpply) 610 generid$70 formulary brand 5170 non-formulary brand If a generic drug is available and member chooses abrand-name drug, member pays the difference between the brand-name price and the generic price, plus any coinsurance. In some cases, this can amount to the full cost of the brand-name drug. Health support Online Health Assessment and Coaching Modules • Heahh Guides and Nurse Guides • Dedicated Nurse Support • inducted with your plan Fitness Program • Employee Assistance • 24-Hour Nurse Advice Llne • Heahhy Start Prenatal Support • Stap-Smoking Support How wst sharing is calculated Copays are flat fees you p at the time you receive a servke. Coinsurance is the percentage of charges you pay for a servke. It's based on the allowed amount. Deductible Is the ortion of the allow d amount ou t All d i h p e y mus pay. owe amount s t e negotiated amount that network providers have agreed to accept as fuU payment at the time our dai i N d y m s processe . onpartkipating providers have not agreed to accept our atlowed amount as payment in full. Your cost sharing may be much greater when you use a nonpartcipating provider. Y-sit bluecrossmn.com far more information about nonparticipating prover payment. ' For highest level of coverage, use Select network providers for chlrapractlc and behavioral health services. Far aB other seMces, use the Blue t7oss network. BlueCross BlueShield ~ ~ • ~ of Minnesota • e xne~dnbe~c~,mwnuranf,o~.°~ (Plan number 113) F5986R27 (4/09) "" Physkal, occupatlanal and speech therapy servkes are limited to a 5500 Btaxlmum per calendar year ThisisoNyanoutGne~planbenefits.The<onUadandcertificateindudecompletedetailsofwnatBandisn'tcovered.servicesnotmvered inckrdeeyeglasses,hearingaids,itemspdmarByusedforaran-medkalpurpose,over-the-couMerdngslnutrttkmalsupplernents,servkes that are cosmetk, experimental, not medic~ly necessary, or covered ty vrorkers' compensation «no-ra<rt crab tnwrance. Preexisting condhammaynott~ecoveredforaNmftedperiodofYrne.ThistkratareducedtypriorcoMkxpusrnverageanddoesnRapplytopregnanry, newborns, adopted chtdren or handicapped dependents. We feature a large network of heahh care providers. Each provider a an independentcontractorand is notouragent. Nonparticipating providers do not have contractsvrith Bkce Cross and Blue ShieM of Minnesota. Benefits are effective July 1, 2009 through June 30, 2010.