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2013 - City of Ramsey
<br />LOGIS Medical Plans
<br />The information contained herein is subject to the disclosure and disclaimers and the final page of this illustration
<br />arrier:
<br />Plan
<br />Network/RX Formula
<br />r
<br />I
<br />BCBSMN BCBSMI�
<br />$30 Copay Plan 'Mil. $1500 H N
<br />Flex Rx Aware/Flex Rx
<br />BCBSMN
<br />$2500 HRA
<br />Flex Rx
<br />1
<br />1
<br />BCBSM
<br />$4000 HRA
<br />Flex Rx
<br />In -Network Plan Design Features
<br />Lifetime Maximum
<br />Annual Maximum
<br />Deductible CY
<br />Coinsurance
<br />Medical Out -of -Pocket Maximum (includes
<br />Medical & Rx)
<br />Preventive Care
<br />Office Visit/Urgent Care
<br />Convenience/Retail Care Clinic
<br />Lab Et Pathology
<br />X-ray Et Other Imaging
<br />Inpatient Hospitalization
<br />Outpatient Hospitalization
<br />Emergency Room Facility
<br />Emergency Room Physician
<br />Prescription Drugs (Rx)
<br />Rx Out -of -Pocket Maximum
<br />Generic/Brand/Non-Formulary
<br />Specialty
<br />Mail Order
<br />Out -of -Network Plan Design Features
<br />Deductible
<br />Out -of -Pocket Maximum (includes medical
<br />and rx)
<br />Coinsurance
<br />Employee Only
<br />Employee + Spouse
<br />Employee + Children
<br />Family
<br />Unlimited
<br />N/A
<br />None
<br />100/0%
<br />$1,200/person;
<br />$5,000/family
<br />100/0%
<br />$30 copay
<br />100% (copay waived)
<br />100/0%
<br />100/0%
<br />100/0%
<br />100/0%
<br />$75 copay
<br />100% after copay above
<br />Open formulary with a
<br />mandatory generic
<br />N/A
<br />80/20% with a min/max
<br />copay of $10/$25 per script
<br />80/20% - capped at $200 per
<br />script per month
<br />80/20% with a min/max
<br />copay of $20/$50 per script
<br />$300/person; $600/family
<br />$4,000/person; 58,000/family
<br />75/25%
<br />$890.00
<br />$1,870.00
<br />$1,781.00
<br />$2,315.50
<br />Unlimited
<br />N/A
<br />$1,500/person; $3,000/family
<br />100/0%
<br />$2,250/person; $4,500/family
<br />100% coverage
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />Open formulary with a
<br />mandatory generic
<br />N/A
<br />80/20% with a min/max copay of
<br />$10/$25 per script
<br />80/20% - capped at $200 per
<br />script per month
<br />80/20% with a min/max copay of
<br />$20/$50 per script
<br />$3,000/person; $6,000/family
<br />$5,000/person; 510,000/family
<br />75/25%
<br />$755.00
<br />$1,586.50
<br />$1,511.00
<br />$1,964.00
<br />Unlimited
<br />N/A
<br />$2,500/person; $5,000/family
<br />100% after deductible
<br />$2,500/person; $5,000/family
<br />100% coverage
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />100% after deductible
<br />Open formulary with a
<br />mandatory generic
<br />N/A
<br />80/20% with a min/max copay of
<br />$10/$25 per script
<br />80/20% - capped at $200 per
<br />script per month
<br />80/20% with a min/max copay of
<br />$20/$50 per script
<br />$4,000/person; $8,000/family
<br />$7,000/person; $14,000/family
<br />65/35%
<br />$696.00
<br />$1,462.00
<br />$1,392.00
<br />$1,810.50
<br />Unlimited
<br />N/A
<br />$4,000/person; $8,000/family
<br />100% after deductible
<br />$4,000/person; $8,000/family
<br />100% (deductible waived)
<br />100/0% after deductible
<br />100/0% after deductible
<br />100/0% after deductible
<br />100/0% after deductible
<br />100/0% after deductible
<br />100/0% after deductible
<br />100/0% after deductible
<br />100/0% after deductible
<br />Open formulary with a
<br />mandatory generic
<br />N/A
<br />80/20% with a min/max copay of
<br />$10/$25 per script
<br />80/20% - capped at $200 per
<br />script per month
<br />80/20% with a min/max copay of
<br />$20/$50 per script
<br />$6,000/person; $12,000/family
<br />$9,000/person; $18,000/family
<br />75/25%
<br />$613.50
<br />$1,289.00
<br />$1,227.50
<br />$1,596.00
<br />Blue Cross Blue Shield Accord Rates
<br />Employee Only
<br />Employee + Spouse
<br />Employee + Children
<br />Family
<br />$858.00
<br />$1,802.00
<br />$1,716.50
<br />$2,232.00
<br />$728.00
<br />$1,529.50
<br />$1,456.00
<br />$1,893.50
<br />$671.00
<br />$1,409.00
<br />$1,341.50
<br />$1,744.50
<br />Aware Network - Open Access
<br />Accord network is a subset of the Aware network that excludes a small number of high -cost providers. Currently the Accord network excludes t
<br />providers: Mayo Clinic Poviders and Hazelden Providers.
<br />Members who receive services at these "out of network' providers will still receive hold -harmless benefits
<br />Rate Guarantees: 2013 = 8.5 %, 2014= 9.5 %, 2015 = 10.5 % & 2016 = 11.5%. Regulatory mandated changes can impact rate caps.
<br />This analysis is an outline of the coverage proposed by the carrier's), based on information provided by your company. It does not include all of the
<br />limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for y
<br />available upon request.
<br />$591.50
<br />$1,242.50
<br />$1,183.00
<br />$1,538.50
<br />he following as in network
<br />terms, coverage, exclusions,
<br />our reference will be made
<br />
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