03/01/2010 Council Packet - Laserfiche WebLink

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Service In- Network Out -of- Network Emergency Care • Urgently needed care at an urgent care Clinic or medical center • Emergency care at a hospital ER • Ambulance $15 copayment $75 copayment 80% coverage $15 copayment 120 visits per year Home Health Care • Physical, speech, occupational & respiratory therapy & home health aides 80% coverage after deductible See In- Network benefit See In- Network benefit 80% coverage after deductible 60 visits per year Durable Medical Equipment • Durable medical equipment & prosthetic devices 80% coverage 80% coverage after deductible Dental Care • Treatment to restore damage done to sound, natural teeth as a result of accidental injury 80% coverage $50 deductible, then 80% coverage up to a $300 maximum Prescription Drugs (up to a 31 -clay supply; 93 -dui supplyIin- nail order) Tobacco cessation products are limited to a 180 clay supply per rear HealthPartners Participating Pharmacy Benefit Non Participating Pharmacy Benefit • Retail Pharmacy • Generic Preferred • Brand Preferred • Non - preferred • HealthPartners Mail Order Pharmacy • Generic Preferred • Brand Preferred • Non- preferred • Specialty Drugs $12 copayment $35 copayment $50 copayment $24 copayment $70 copayment $100 copayment 80% coverage up to a $200 maximum per prescription per month 80% coverage after deductible 80% coverage after deductible 80% coverage after deductible 70% coverage after deductible