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2016 City of Ramsey Plan Choices <br />BluePrint Plan Choices - Allina Network <br />Carrier: <br />Ian <br />I etwork/RX Formulary <br />BCBSMN <br />$2500 HDHP.HRA <br />BCBSM <br />Millw$4000 HDHP.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) - The out-of-pocket maximums <br />for in and out -of -networks accumulate <br />separately. <br />Non -covered charges and charges in excess of <br />the allowed amount do not apply to the out-of- <br />pocket maximum <br />Preventive Care <br />Office Visit <br />Urgent Care (clinic based) <br />Convenience/Retail Care Clinic <br />Lab & Pathology <br />X-ray & 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 />lue Cross Blue Shield BluePrint Rates <br />Employee only <br />Employee + Spouse <br />Employee + Children <br />Family <br />Unlimited <br />N/A <br />$2,500/person <br />$5,000/family <br />100/0% <br />$2,500/person <br />$5,000/family <br />Unlimited <br />N/A <br />$4,000/person <br />$8,000/family <br />100/0% <br />$4,000/person <br />$8,000/family <br />100% (deductible waived) 100% (deductible waived) <br />Primary Care or Specialist visits due to illness <br />or injury 100% after deductible - First two <br />office visits in calendar year -100% <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 />Formulary with a mandatory generic <br />N/A <br />Allina Pharmacy: Generic = $9 copay, <br />Brand = $36 Copay <br />Network Pharmacy: Generic = $10 Copay, <br />Brand = $40 Copay <br />Allina Pharmacy: Generic = $9 copay, <br />Brand = $36 Copay <br />Network Pharmacy: Generic = $10 Copay, <br />Brand = $40 Copay <br />Allina Pharmacy: Generic = $18 copay, <br />Brand = $72 Copay <br />Network Pharmac : No Coverage <br />$881.00 <br />$1,849.50 <br />$1,761.00 <br />$2,289.00 <br />Primary Care or Specialist visits due to illness <br />or injury 100% after deductible - First two <br />office visits in calendar year -100% <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 mandatory generic <br />N/A <br />Allina Pharmacy: Generic = $9 copay, <br />Brand = $36 Copay <br />Network Pharmacy: Generic = $10 Copay, <br />Brand = $40 Copay <br />Allina Pharmacy: Generic = $9 copay, <br />Brand = $36 Copay <br />Network Pharmacy: Generic = $10 Copay, <br />Brand = $40 Copay <br />Allina Pharmacy: Generic = $18 copay, <br />Brand = $72 Copay <br />Network Pharmac : No Coverage <br />$763.00 <br />$1,603.00 <br />$1,526.50 <br />$1,984.50 <br />BluePrint plans include Chronic Condition Management Coverage, Resiliency Training, Nutrional Counseling Medication Therapy <br />Management services see the benefit summary for more details on those benefits <br />Network Definitons: <br />BluePrint - Allina Health Network in MN (Blue Card PPO outside of MN) <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 <br />all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves <br />must be read for those details. Policy forms for your reference will be made available upon request. <br />