Agenda - 10-21-2002 - 4 - Laserfiche WebLink

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Benefits Changes Blue Cross Preferred Provider Plan (PPO), Blue Options Plan 1 and Blue Options Plan 2 Services Preferred Provider Plan Option 1 -Blue Options Plan 1 Options 2&3-Blue Options Plan 2 In-Network Out-of-Network 1n-Network Out-of-Network In-Network Out-of-Network Yearly Deductible $200 $300 $250 $500 $500 $1,000 Family $600 $900 $750 $1,500 $1,500 $3,000 Coinsurance Maximum Individual $1,000 $2,000 $1,000 $2,000 $2,000 $4,000 Coinsurance Maximum Family $2,000 $4,000 $3,000 $6,000 $6,000 $12,000 Physician Services-Office 90%after deductible 80%after deductible 100%after$10 copay 70%after deductible 100%after$10 Copay 70%after deductible Visits,PMD P Y Office Visits,Specialists 90%after deductible 80%after deductible 100%after$20 copay 70%after deductible 100%after$20 copay 70%after deductible Urgent Care Office Visit 90%after deductible 80%after deductible 100%after$20 Copay 100%after$20 copay 100%after$20 copay 100%after$20 copay Maternity 90%after deductible 80%after deductible 100%after$20 copay 70%after deductible 100%after$20 copay 70%after deductible Outpatient Diagnostic 90%after deductible 80%after deductible 100% 70%after deductible 100% 70%after deductible Surgery(in&Out) 90%after deductible 80%after deductible 90%after deductible 70%after deductible 90%after deductible 70%after deductible Inpatient/Outpatient-Medical 90%after deductible 80%after deductible 90%after deductible 70%after deductible 90%after deductible 70%after deductible Short Term Therapy-Speech, $90 copay PMD-$20 copay 70%after deductible - $10 copay PMD-$20 copay 70%after deductible - Occupational,Respiratory and 90%after deductible 80%after deductible for specialist, 30 visits per Maximum 30 visits per for specialist-30 visits per Maximum 30 visits per Physical and Chiropratic benefit period. Calendar Year benefit period. Calendar Year Preventive Care(Routine Physicals,Well Child Care and 90%after deductible 80%after deductible $10 Copay PMD-$20 for Not available $10 copay PMD-$20 for Not available Immunizations specialist,. specialist. Vision Not available Not available $10 copay for eye exam Not available $10 copay fore a exam Not available Emergency Services 90%after deductible 80%after deductible $100 copay,waived if $100 copay,waived if $100 copay,waived if $100 copay,waived if admitted admitted admitted admitted Hospital Services(Inpatient, Outpatient,Maternity/Delivery, 90%after deductible 80%after deductible 90%after deductible 70%after deductible 90%after deductible 70%after deductible Ambulatory Surgical Facility) Prescription Drugs Tier 1 $6 Copay;Tier 2$12 Tier 1 $6 Copay;Tier 2$12 Tier 1$5 Copay;1 jer2$15 Tier 1 $5 Copay;Tier 2$15 Tier 1 $10 Copay;Tier 2$20 Copayment+charge over Short Term Supply Copay;Tier 3$18 Copay(1- Copay;Tier 3$18 Copay(1- Copay;Tier 3$30 Copay(I- Copay;Tier 3$30 Copay(I- Copay;Tier 3$30 Copay " �' 30 Day Supply) 30 Day Supply) 30 Day Supply) 30 Day Supply) (1-30 Day Supply) In-network allowed amount 'Tier 1 $12 Copay;Tier 2 *Tier 1 $15 Copay;Tier 2 er 1 $30 Copay;Tier 2 Extended Supply Benefits $24 Copay;Tier 3$36 Copayment+Charge over $45 Copay;Tier 3$90 Copayment+Charge over $60 Copay;Tier 3$90 Copayment+c.harge over Copay(31-90 Day Supply) in-network allowed amount Copay(31-90 Day Supply) in-network allowed amount Copay (31-90 Day In-network allowed amount Supply) healppocomp10/3/2002 ��