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5.4. ERMUSR 09-11-2012 Elk River M Municipal Utilities 13069 Orono Parkway P.O. Box 430 Elk River, MN 55330 (763) 441-2020 UTILITIES COMMISSION MEETING TO: FROM: Elk River Municipal Utilities Commission Theresa Slominski—Finance and Office John Dietz—Chair Manager Daryl Thompson—Vice Chair Al Nadeau—Trustee MEETING DATE: AGENDA ITEM NUMBER: September 5, 2012 5.4 SUBJECT: Review and Consider Insurance Options and Renewal BACKGROUND: This year we again have a great health insurance renewal. While it is not a decrease this year, there is no change from last year, which means a 0% increase. We also are a"grandfathered plan" which means that we have not changed our health plan since health care reform was introduced and, therefore, have not had to comply with the reduction in benefits of the standard plans' requirements. DISCUSSION: At the annual City, County and Other Government Agency insurance meeting on August 27, we received our health insurance renewal contract with the 0% increase. Typically we don't discuss our insurance options until the October meeting (when we review health and dental, wages, and other benefits) however, we have a timeline imposed on us this year for other reporting requirements relating to our health insurance that requires a decision before October 1st. The reporting requirement is a Summary of Benefits and Coverage (SBC) document that needs to be distributed to all participants of the plan 30 days prior to renewal (which would be December 151.) Blue Cross and Blue Shield (BCBS) will prepare this document for us if they are notified by October 151 what plan we are participating in for 2013, otherwise we will have to prepare this document ourselves. Since there are many specific requirements for this document, it is preferable BCBS prepare it. (Information on this SBC requirement is attached for your review.) Given that the renewal is a good one, and the timeline is so short for a decision, staying with the current plan, at the current rate, with no changes, is a valid option. There are some options of changing to a standard plan, however, that would mean a reduction in benefits of higher co-pays, 3 1NATuP1 r3 E Reliable Public Power Provider P O W E R E D T o S E R V E higher deductibles, and lower coverage amounts. (This would also mean we would no longer be a grandfathered plan.) These options are presented for your information along with the Medical Benefit Summaries of the options so you can compare the change in benefits of the various plans. Plan 4 is very similar to our current plan but has a slightly higher co-pay and prescription costs, and a higher deductible for out-of-network providers. Plan 113 is an 80% option (versus 100% of current plan), has a higher co-pay and prescription cost, and a higher deductible for out- of-network providers. The CDHP 1200 is a Health Savings Account (HSA) plan. When we discussed the potential of introducing an (HSA) option last year it was not met with much enthusiasm and probably shouldn't be considered this year either. Previously, the Wage and Benefits Committee reviewed both health and dental insurances together along with wages. Given the tight timeline, this committee involvement has not been utilized for this piece. Additionally, the dental insurance renewal contract is not available until after September 141h and so we are only considering health insurance at this time. FINANCIAL IMPACT: Renewing the current plan has no financial impact. Switching to a different plan has some cost savings ranging from 6% to 11% but also includes loss of benefits. ACTION REQUESTED: A decision is needed for the health insurance plan for 2013 by October 1st. Staff recommends renewing the current plan at a 0% increase. If other options are to be considered, staff recommends the Wage and Benefits Committee be consulted and then a special commission meeting called to approve the committee recommendation. ATTACHMENTS: 2013 Group Renewal Bulletin with SBC information Medical Rate Summary Summary of Benefits for current Gold plan, Plan 4, Plan 113, and $1200 CDHP R.��. �� e NATURE Reliable Public IPOINIER / -A �„�I Power Provider POWERED T o S EPEE s , . rt I r ° p 0) l- c c u w m 5 0 001 3 S O a) a a 846 mV- w o c 0- 2 a a 00 w ° 2 v 111: 11 .c-. O 7 as a O U) Q° T a)o m N O c m w. m a) -O 0 "0 C a) Q CO N a �> to m 'O 0 N O. C ai p 3 CO 0 a) ° v r 0 O J-C a. cT c vc- c E C c N '�0 N O o O C L a,. C L m 0 10 Co 0 > a) N a) U E T ` t w U E a) y Y C co a) 9a — i- o 7 o 0 ° .2 O co E as m L ,t.., c O C C w -0 N m 3 m . p) C c a) 0 a) C a) 7 0 a N �. c — 7 N Q- as to 2 c O to 0 0@ C d a C 2 a� v CO Z' a) C -° a) w O m �. c c — Cu o m CO p m < c m E N a) (` a = a) o a L. c ~ O 2 0 o co 0 2 N 7 0) a. 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BlueCross BlueShield Elk River Municipal Utilities Vas) of Minnesota • • .. r A,,.,•rithi "r,AS„,,":h„a.,,os„" Double Gold Ne CAA-lei-EMT PL 44" L-3C Effective Date: 1/1/2013 THIS IS ONLY A SUMMARY AND IS SUBJECT TO THE TERMS OF THE CONTRACT** IN - NETWORK PROVIDERS OUT-OF-NETWORK PROVIDERS Calendar Year Deductible $0 Single $0 Family $300 Single $900 Family Medical Calendar Year Out-of-Pocket Maximum $1,500 per person In Network $5,000 per person Out of Network `` Non i overeii i barges and charges in excess of our allowed amount do not Prescription apply to the out-of-pocket maximum $750 Single $1,500 Family Coinsurance 100% Deductible then 80%coinsurance If non-participating provider services are 'Payment for Participating Network covered,you are responsible for the Benefit Payment Levels Providers as described. Most payments difference between the billed charges and are based on allowed amount allowed amount. Most payments are based on allowed amount. Lifetime Maximum per Person Unlimited Dependent Child Age Limit To age 26, through the calendar month of the birthday. COVERED CHARGES Preventive Care • Well Child Care through age 5 100% 100% • Prenatal Care • Routine Physicals ages 0 and older • Office Visits • Cancer Screening 100% Deductible then 80% coinsurance. • Routine F fearing arid Vision Exams • Imrnun'¢alicns and Vaccinations - - Ph sician Services • In-Hospital Medical Visits • Surgery and Anesthesia 100% Deductible then 80%coinsurance. • Inpatient Lab and X-rays.etc • Office Visits due to Illness or Injury 100%after$20 co-pay Deductible then 80% coinsurance. • Urgent Care (Clinic Based) • Outpatient Lah and X-ray 100% Deductible then 80%coinsurance. • Allergy Injections and Serum 100% Deductible then 80%coinsurance. Other Professional Services • Chiropractic Care 100%after$20 co-pay with Blue Select Deductible then 80%coinsurance with providers. - Extended Network providers. No coverage with non•artici•atin• •roviders. • Home Health Care 100% Deductible then 80%coinsurance • Physical Therapy, Occupational Therapy, Speech Therapy 100%after$20 co-pay Deductible then 80%coinsurance. $500 maximum benefit per calendar year for non-participating providers. IN -NETWORK PROVIDERS OUT-OF-NETWORK PROVIDERS npatient Hospital Services 365 days of medically necessary care -100% Deductible then 80%coinsurance in an avera.e semi-private room Out•atient Hos t ital Services • Diagnostic Tests • Pre-Admission Tests and Exams 100% Deductible then 80%coinsurance • Lab and X-Ray • Chemotherapy and Radiation Therapy • Physical, Occupational and Speech Therapy x u A • Kidney Dialysis 100% Deductible then 80%coinsurance • Scheduled Outpatient Surgery • Non-emergency— Illness Related visits • Urgent Care(Hospital based) '1100% Deductible then 80%coinsurance Eme tenc Care • Emergency Room x100%after$75 co pay • Physician Services "100%e 100% Ambulance - Medically necessary flansporT to nearest r�c0ity r " Medical Supplies Behavioral Health Care Mental Health and Chemical Dependency Care) • Inpatient Care -10,0% `;„-e, = Deductible then 80%coinsurance • Outpatient Care "100°4 '' Deductible then 80%coinsurance • Professional Care 2100%after.$20 office Gall copay,,; Deductible then 80%coinsurance. Prescri s tion Dru.s •etail—31day limit '$0 Co-pay g"@neric '" $35 Co-pay'Bra'nd Formulary $50 Co-pay Brand Non:formulan 90dayRx—90 day limit '$0 Co=pay genenc , ' (PruneMail and Participating Retail y$70 Co-pay;Brand Formulary .,r y Pharinacles) �$125 Co-pay,Brand Non::-formulary ` **This is only an outline of plan benefits.The contract and certificate include complete details of what is and isn't covered. Services not covered include items primarily used for non-medical purposes, over-the-counter drugs/nutritional supplements, services that are complementary, experimental, not medically necessary, or covered by workers' compensation or no-fault auto insurance. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Nonparticipating providers do not have contracts with Blue Cross and Blue Shield of Minnesota. Blue Cross and Blue Shield of Minnesota is an independent licensee of the Blue Cross and Blue Shield Association. AWARE GOLD® WITH COPAY PLAN 4 • ` MN WITH AWARE® NETWORK For the health of as JULY 1, 2012 IN NETWORK OUT OF NETWORK ¢I t a vv�.rt d `' e , xS I $0 $3,000 per erson rY , , ,, _. y 4- . I . + s o- -1d r F m. °i St it r. . ' c,^ $9,000 per family G nl�Gµ It 4 t'y:is ri,i131tr+ ' xs- ar r �F ' $1,500 per person $9,000 per person tr--f+ +t a + r. + I r"�. i. J t fl j lir, a r p rotgl . ' s + - $1,000 per person/$2,000 per family , �QF IlctWed applies to prescription drugs a d to o�° • c- Siiinbm t, Ntlif:. ,r-0 ,at�"7 ypc utn } ;$ r Unlimited P r .m care" t ��ty ,`'AC�' *, F. • 'A—u .Bre AO ag8, ,�,�u ''1"{f•G 1, . 100% 100% • n care F�5; ; i"i 3 s i 100% 100% • ' e,ett nn -1 s, ,. °.-.r4 > 100% Deductible then 50%coinsurance • ❑ [!r {t$ v t10 ° tit 4rr 100% Deductible then 50%coinsurance •1.1111':","4' s'liCalaa , � 1 14' ,,: t." 100% Deductible then 50%coinsurance • R',y x v4 4,,,n. t, ``4ta' ..., . It, 100% Deductible then 50%coinsurance ft:Et A } +f y+ ]pd r } ir°:3 } 100%after$25 copay Deductible then 50%coinsurance a ld 4r ., 'lug �' r'I a „4•18:2-i:.,0)� t , P Y • H f re Ontd+bee0d)+ , " f , ' 100%after$25 copay Deductible then 50%coinsurance R r f t4 - h PIUIG t.fi-grz '' 100% Deductible then 50%coinsurance • ,-tt- lrrmagfpg ' ', ,; F 100% Deductible then 50%coinsurance • .r f; :n)ectierte"and@ervrp , + ' 100% Deductible then 50%coinsurance «r t ` ` 100%after$45 copay Deductible then 50%coinsurance • , °.,. �, aka, w .:',: 100% Deductible then 50%coinsurance ii: ■ ,trapr09man !short m�i " 100%after$25 copay No coverage • J RS*tli�`rapy -'' _ 100% No coverage ;health Care;j, t',.':' ' av S 100% No coverage •p, y1ldg tb rgpyt pcc, q r,�p speech herapy 100% No coverage • behavioral heaps end cheml I eendency care _ 100%after$25 copay Deductible then 50%coinsurance Iiiiiiiebt bosPitei gend" > • mph9dinQ behavioral heaith and ghemicel 100% Deductible then 50%coinsurance dependency services Otttttbltlenk hospital services • diegndaticlmaging? 100% Deductible then 50%coinsurance • sghedgled outpatient atrrgef)+ 100% Deductible then 50%coinsurance • urgent care(hospital-based} 100% Deductible then 50%coinsurance • Including behavioral health and chemical dependency 100% Deductible then 50%coinsurance sgrvlces Emergency care 100%after$100 copay •emergency room • physician charges 100% •ambulance(medicallynecessary transport to the nearest . 80% facility+) MedlSateuppl1eei,_> ,. 80% I 50% Blue Cross®and Blue Shield®of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association IN NETWORK I OUT OF NETWORK . _ - ' Cr7; $12 copay $12 copay -; .va $45 copay $45 copay 3y ii> - _ $90 copay $90 copay +''i a 20%to a maximum of$200 per No coverage j c prescription SB 3 - - $24 copay - _ - - w„ $90 copay - =e $180 copay— -------- -------- 90dayRx applies to participating and/or mail service pharmacy. il Identified specialty drugs purchased through a specialty pharmacy network supplier are eligible for coverage(no coverage for specialty drugs purchased se wog ”; ,'fl through a nonparticipating specialty pharmacy supplier). f +HIV,k a The patient will pay the difference if a brand-name drug is selected when a I.trori4. generic drug is available. t' E. `; ' ,qis The drug list uses a step therapy program.Visit the prescription drugs section rgitiVedtre'7.,y p,{ ' ' i it 1Y+ of www.bluecrossmn.com for more details. AT7... Your out-of-pocket costs depend on the network status of your provider.To check the status of a provider,call Blue Cross and Blue Shield of Minnesota customer service or visit bluecrossmn.com. Lowest out-of-pocket costs:in-network providers Higher out-of-pocket costs:extended and out-of-network participating providers Highest out-of-pocket costs:out-of-network nonparticipating providers(You are responsible for the difference between Blue Cross'allowed amount and the amount billed by nonparticipating providers.This is in addition to any applicable deductible,copay or coinsurance.Benefit payments are calculated on Blue Cross'allowed amount,which is typically lower than the amount billed by the provider.) This is only an outline of plan benefits.The contract and certificate include complete details of what is and isn't covered.Services not covered include eyeglasses,hearing aids,items primarily used for a non-medical purpose,over-the-counter drugs(except as specified in the Certificate of Coverage), nutritional supplements,services that are cosmetic,experimental,not medically necessary,or covered by workers'compensation or no-fault auto insurance.Preexisting conditions may not be covered for a limited period of time.This limit is reduced by prior continuous coverage and doesn't apply to pregnancy,newborns,adopted children,individuals under 19 or handicapped dependents.We feature a large network of health care providers. Each provider is an independent contractor and is not our agent.Nonparticipating providers do not have contracts with Blue Cross and Blue Shield of Minnesota.Please note:Benefits are subject to regulatory approval. UNMATCHED SERVICE HEALTH AND WELLNESS TOOLS When you call customer service,Health Guides answer your questions, You get a comprehensive suite of health support offerings including:24- resolve any issues and refer you to additional resources that can help you Hour Nurse Advice Line,Dedicated Nurse Support for ongoing save money and live a healthy life. health conditions,Employee Assistance Program,Enhanced Stop- Smoking Support,Fitness Discounts,Health Guides and Nurse Guides, HEALTH CARE COVERAGE ANYWHERE IN THE WORLD Healthy Start®Prenatal Support,Online health assessments,Online More than 97 percent of Minnesota doctors and hospitals are in our health coaching networks,where you always get the best benefit for your dollar.And you never need a referral.You're also"in network"virtually anywhere you ONLINE CARE ANYWHERE` go in the United States with the BlueCard®traditional network and Talk to a provider online,when it's convenient for you.Online Care internationally through the BlueCard Worldwide®network. Anywhere gives you online access to providers who can answer To find in-network providers,visit"Find a doctor"at bluecrossmn.com. questions,make diagnoses and prescribe medications as appropriate For providers in Minnesota,search the Aware®network. all from your home or office.For information,go to Onli neCa reAnyw hereMN.com. SAVE MONEY ON BETTER HEALTH *Note:Available only in Minnesota.Visits are not covered by your You'll get discounts on:Acupuncture and massage therapy,Weight health plan;therefore,payments do not apply toward your deductible. Watchers,LASIK eye surgery,Medical equipment,Disposable medical supplies and more END-OF-YEAR DEDUCTIBLE CARRYOVER When you haven't met your calendar-year deductible,you can"carry QUICK,HASSLE-FREE CLAIMS PROCESSING over"approved claims expenses incurred in October,November and Your claims are handled quickly,efficiently,accurately and without December to help meet the deductible for the following year.The annual hassle. out-of-pocket maximum begins again in January of each year. For more information,contact your employer or visit bluecrossmn.com. Blue Cross®and Blue Shields of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association COMMUNITY BLUES" WITH COPAY PLAN 113 WITH AWARE® NETWORK For the health of all. JULY 1, 2012 41.., IN NETWORK OUT OF NETWORK 1 {t i'. .`ttY" 41:,:r-,r0,./.411.:tae 'd ° .a ? $0 $3,000 per person •: v �I ., 1.01'-- r . E "hq pP�t, '� �$ 4 +asR�� w� ��i ew i , $9,000 per family 4r , , ' ," $2,000 per person $9,000 per person T + x i } . r F pub "FReIi _i $6,000 per family +2+ N� cad c h r ep riles in e8 v �4o11 $1,000 per person/$2,000 per family amour) 0 no to ee of lbdtet'tneltimu li 4 , applies to prescription drugs 6I ;,la1Fh� ' petgRtt` xl' r' u,a,? Unlimited P ' ) zpu . . c r ' fai art �9 aQ@19 '.y I rtl 3 . 100% 100% t n ',Ipf@e �1 ' 100% Deductible then 50%coinsurance 1, l d Yyccp3 tl4r '! s 100% Deductible then 50/o coinsurance • t t p s , tf- ., ' 100% Deductible then 50%coinsurance e c ten �exam :'9' ri r 100% Deductible then 50%coinsurance ,rye m ... r Pitt (7e t C i i1 a ;! t ells 4��p h�8SS pl'tNury h .1;t: - 100%after$30 copay Deductible then 50%coinsurance •0tr�` * n c tC-,kad) f 100%after$30 copay Deductible then 50%coinsurance • a ealth cl us - 100% Deductible then 50%coinsurance tat n5(ieimaging ; 100%;80%for inpatient services Deductible then 50%coinsurance 80% Deductible then 50%coinsurance •'aped SryedignS a- serum-, 100% Deductible then 50%coinsurance • sppctajty 100%o after for copay I - 100%;80%for inpatient services Deductible then 50%coinsurance 011.r tne,.ssippal sorvIces • ehc rngnipulat1on , 100%after$30 copay No coverage • i1C"1IctherapY 80% No coverage it bgrne ieafth care ' - ' 80% No coverage • gljysIgaltherapy,9,GF,�{V.ritgl therapy,speech thettapy 80% No coverage a behavioral health and.chemical dependency dare 100%after$30 copay Deductible then 50%coinsurance In-tlint hospital services • including behavioral health and chemical - 80% Deductible then 50%coinsurance dependency services Outpatient hospital services •diagnostic imaging 3 80% Deductible then 50%coinsurance •scheduled outpatient surgery 80% Deductible then 50%coinsurance • urgent care(hospital-based) "` 80% Deductible then 50%coinsurance • including behavioral health and chemical dependency 80% Deductible then 50%coinsurance services Emergency care 80% •emergency room - • physician charges, =:` 80% t,.ambulance(medPeailynecessa'ry!transport to the nearest'`;=; ° facility). s,, Medical S 1pptfas; !, „N n, 80% I Deductible then 50%coinsurance Blue Cross®and Blue Shield®of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association IN NETWORK OUT OF NETWORK 4 a. . - - - $12 copay $12 copay s $45 copay $45 copay - - $90 copay $90 copay 20%to a maximum of$200 per No coverage { prescription 'i ° 9 A $24 copay - - - $90 copay ifilliaWItarff=-14amfratepcirefr 410 -$180 copay.------------- 90dayRx applies to participating and/or mail service pharmacy. Identified specialty drugs purchased through a specialty pharmacy network W4,1014,50410042,100545fianyeet". supplier are eligible for coverage(no coverage for specialty drugs purchased through a nonparticipating specialty pharmacy supplier). s ,k ,{ ry . a a ,. The patient will pay the difference if a brand-name drug is selected when a Is $ - ° a? i4 a ' generic drug is available. r '', 4.. „' The drug list uses a step therapy program.Visit the prescription drugs section kt `'u ; m " of www.bluecrossmn.corn for more details. Y'.4 Ik 4' 'i I� ��* 1 Li', s1444 c'" . ;r-?..- ems msti-II4 )4:9- : f44j+c444. Your out-of-pocket costs depend on the network status of your provider.To check the status of a provider,call Blue Cross and Blue Shield of Minnesota customer service or visit bluecrossmn.com. Lowest out-of-pocket costs:in-network providers Higher out-of-pocket costs:extended and out-of-network participating providers Highest out-of-pocket costs:out-of-network nonparticipating providers(You are responsible for the difference between Blue Cross'allowed amount and the amount billed by nonparticipating providers.This is in addition to any applicable deductible,copay or coinsurance.Benefit payments are calculated on Blue Cross'allowed amount,which is typically lower than the amount billed by the provider.) This is only an outline of plan benefits.The contract and certificate include complete details of what is and isn't covered.Services not covered include eyeglasses,hearing aids,items primarily used for a non-medical purpose,over-the-counter drugs(except as specified in the Certificate of Coverage), nutritional supplements,services that are cosmetic,experimental,not medically necessary,or covered by workers'compensation or no-fault auto insurance.Preexisting conditions may not be covered for a limited period of time.This limit is reduced by prior continuous coverage and doesn't apply to pregnancy,newborns,adopted children,individuals under 19 or handicapped dependents.We feature a large network of health care providers. Each provider is an independent contractor and is not our agent.Nonparticipating providers do not have contracts with Blue Cross and Blue Shield of Minnesota.Please note:Benefits are subject to regulatory approval. UNMATCHED SERVICE HEALTH AND WELLNESS TOOLS When you call customer service,Health Guides answer your questions, You get a comprehensive suite of health support offerings including:24- resolve any issues and refer you to additional resources that can help you Hour Nurse Advice Line,Dedicated Nurse Support for ongoing save money and live a healthy life. health conditions,Employee Assistance Program,Enhanced Stop- Smoking Support,Fitness Discounts,Health Guides and Nurse Guides, HEALTH CARE COVERAGE ANYWHERE IN THE WORLD Healthy Start®Prenatal Support,Online health assessments,Online More than 97 percent of Minnesota doctors and hospitals are in our health coaching networks,where you always get the best benefit for your dollar.And you never need a referral.You're also"in network"virtually anywhere you ONLINE CARE ANYWHERE"-" go in the United States with the BlueCard®traditional network and Talk to a provider online,when it's convenient for you.Online Care internationally through the BlueCard Worldwide®network. Anywhere gives you online access to providers who can answer To find in-network providers,visit"Find a doctor"at bluecrossmn.com. questions,make diagnoses and prescribe medications as appropriate— For providers in Minnesota,search the Aware®network. all from your home or office.For information,go to O nlineCareAnywhereMN.com. SAVE MONEY ON BETTER HEALTH *Note:Available only in Minnesota.Visits are not covered by your You'll get discounts on:Acupuncture and massage therapy,Weight health plan;therefore,payments do not apply toward your deductible. Watchers,LASIK eye surgery,Medical equipment,Disposable medical supplies and more END-OF-YEAR DEDUCTIBLE CARRYOVER When you haven't met your calendar-year deductible,you can"carry QUICK,HASSLE-FREE CLAIMS PROCESSING over"approved claims expenses incurred in October,November and Your claims are handled quickly,efficiently,accurately and without December to help meet the deductible for the following year.The annual hassle. out-of-pocket maximum begins again in January of each year. For more information,contact your employer or visit bluecrossmn.com. Blue Cross®and Blue Shield®of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association Pti oMf nae5hield inesot $1 ,200 CDHP !d ,m °,''. <'n'.,-.,4,',', THIS IS ONLY A SUMMARY AND IS SUBJECT TO THE TERMS OF THE CONTRACT** i `rwa 451i :, ,, ` vt; Out of Network � T ri ,litt-dsrt•salf-dsfar, tat- -AL_y't ,, 3 r+»k ,J n '. l"/-s tnlr., "'R'tmrty �t[]e�SfPeU. :- Calendar Year Deductible Saff i r "e '�Gjay'i a y eraw r Calendar Year Out-of-Pocket Maximum ittg ..i '4: Pti l, , 1 he in and out-of-net,.crk maximums �_ ' n CW_ t 4 , f ,, Medical and Prescription Cross.ripply rte' r a „.y,a54.1 h-a1# t ;V ,I $3,500 Single $6,500 Family tvar.-eon r red r ha gr and ch-r,I ir. g"� '11*P ir}}t°., 't, ,� . a ss t C ui allo rer' amount do not S y` -LIT;Cp' { i '#° T apply in the mbof-tr r ket maximum p' r „u ..amr. 41¼ , e,�fi j , a . Coinsurance `fl Tt ,. LeL ri a+'U , " 80% �1/44 fia+ If non-participating provider services are p;a" , °, a covered,you are responsible for the • e+to .At°F ,i'91-M difference between the billed charges and Benefit Payment Levels f{T"ttT.. - ,w '+ 'i t ``l`t'* allowed amount. Most payments are }C i " ° -1 ;. based on allowed amount. Lifetime Maximum per Person yrtli`tr1T ',' 194Ffigt.F " 1 t Dependent Child Age Limit To age 26 through the calendar month of the birthday COVERED CHARGES Preventive Care • Well Child Care through age b ,m >e n =r i : �w ' n r ; (Mt. 100/ • Prenatal Care �a,�rr I•i? ' s .r r#�za � ,i i :�= • t #"h Routine F'I ysicals ages 6 and olCer i t ts' 01 � ,. a °, 0li.c Vint. ➢, , eat i ` , 4 $ ' [1 t , a° . • t � g z • Cancel Screening a 4 ° Ws i ` Deductible then 80%coinsurance. • Routine Hearing and Vision Exams a pi p • , 1� „x, `r a • Immunizations and Vaccinations ,, 1 -n ,° 1.=' Ph sician Services • In Hosp'tal Medical Visits ' ^ Yy . , • Surgery and Anesthesia yGkfbleFN#en 100°t^g, n�,ur Deductible then 80%coinsurance. • Inpatient lab and Xrays.etc ', _, wax a -,+ten e . • Office Visits due to Illness or ct Injury bl Deductible then 80%coinsurance. • Urgent Care (Clinic Based �eUf i thgn 1qps. " +rt t i• Outpatient Lab and X-ray kit*udlb`Cl theii,100%tco` "spraFl Deductible then 80%coinsurance. • Allergy Injections and Serum i 'u° Jgfh,Brj 1'gq°3or� fns -',T t' Deductible then 80%coinsurance. Other Professional Services • Chiropractic Care Deductible then 1004 coitsuti nee. Deductible then 80%coinsurance -•udihle then 100%comst{ratice. • Hans I Icalth Care - Deductible then 80%coinsurance. • Physical Therapy, Occupational Therapy Speech Therapy .'Deductible then 100%winsurance- Deductible then 80%coinsurance In Network Out of Network Inpatient Hospital Services 365 days of medically necessary care _Deduct'lle (hen coinsurance Deductible then 80%coinsurance. in an average semi-private room. Out•atient Hos•ital Services • Diagnostic Tests • Pre-Admission Tests and Exams E-J.icNt.e tCri C'G - n_u-anue - Deductible then 80%coinsurance. • Lab and X-Ray • Chemotherapy and Radiation Therapy - - -• Physical, Occupational and Speech - - - Therapy 0 - r: tlle nth 100.- ir ura,r;� - Deductible then 80%coinsurance. • Kidney Dialysis - _- - - - -• Scheduled Outpatient Surgery - _• Non-emergency-Illness Related visits 5 • Urgent Care(Hospital based) 0, - 1 h- j; '- E Deductible then 80%coinsurance. Emer•enc Care _ • Emergency Room nth._ _r he then 'h_ u ur-xrct-• Physician Services Ambulance - - - - - DL aintir.H .H1.- Medically necessary transport to nearest facility - - Medical Supplies Behavioral Health Care Mental Health and Chemical Dependency Caret • Inpatient Care _Door,ct le then 'r " co Deductible then 80%coinsurance. • Outpatient Care G cucuble the, ,- rnr'2c 1 Deductible then 80%coinsurance. • Professional Care Dh unic1H- (heri 111 nur_,r Deductible then 80%coinsurance. Prescri•tion Dru•s Retail-31 day limit D hunt tde r ' ' ,r;urar�e - Flex RX Formulary !I czar_ 6 _nFUn nsf _r a Pr err 1 u s IT Gene- - J+ble .4rid n-ns ticnJ .el cd uutien?(-ay' r,e d'te.rencc 90dayRx-90 day limit 1PnmeMad and Participating Retad Pharmacies) ' r ti„I_ i .r.3G'u n i I ^.in i-b- I ,pH., to r-a:,e_1 ❑d, e ritl?-'.n:'o Note:There are three drug plans available Plan A: Drugs subject to deductible then 100% Plan B: Greater of a$14 co-pay or 25%coinsurance up to a$750 per person $1,000 family drug out-of-pocket Plan C: 25%coinsurance up to a$750 per person/$1,000 family drug out-of-pocket Please discuss these plans with your account manager Deductible amounts and out-of-pocket maximums may increase annually to keep pace with inflation. *"This is only an outline of plan benefits. The contract and certificate include complete details of what is and isn't covered. Services not covered include items primarily used for non-medical purposes, over-the-counter drugs/nutritional supplements, services that are complementary, experimental, not medically necessary, or covered by workers' compensation or no-fault auto insurance. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Nonparticipating providers do not have contracts with Blue Cross and Blue Shield of Minnesota. Blue Cross and Blue Shield of Minnesota is an independent licensee of the Blue Cross and Blue Shield Association. Administered by Blue Cross and Blue Shield of Minnesota, a nonprofit independent licensee of the Blue Cross and Blue Shield Association