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JAN UARY 1, 2010 <br /> CITY OF ORONO (LOGIS) HEALTH CARE PLANS COMPARISON <br /> Open Access, Distinctions, $2500 HDHP/HRA and $2500 HDHP/HSA <br /> � �� ,�,�� _ : ; <br /> I �I Y�� �� t ' .-:.� 1� r=, ! y �9 �� .i a / 9'J s 8 " : <br /> .,i: . ` �s,� rs^"' � ��+� � . � .. l.g�.:',.. <br /> � � �,i� F '° �� j�b: - � - f' �� ��,,�.�, _ � r. � �r� � <br /> .. �`�r ,;n '�' <br /> � �„ 'r+ ) _ :xt�, L � � <br /> �,,_ �tr <br /> . .. . . :,., . . �:,. _�.. , . , , ... , ,_ ...... , <br /> When you receive When you receive ' When you receive When you receive <br /> covered services, covered services, covered services, covered services, � <br /> HealthPartners PAYS: HealthPartners PAYS: HealthPartners PAYS: HealthPartners PAYS: <br /> Physical, Occupational <br /> & Speech Therapy 100%after$30 copay 80% after deductible 100% after deductible 100� after deductible <br /> Mental Health Care 100% after$30 copay 80%after deductible 100%after deductibte 100%after deductible <br /> Chemical Health Care 100% after$30 copay 80% after deductible 100% after deductible 100%after deductible <br /> Chiropractic Care 100% after S30 copay 80%after deductibte 100%after deductibte 100%after deductibte <br /> Convenience Care <br /> Convenience clinics, 100% after$15 copay 80%after deductibte 100%after deductible 100%after deductible <br /> (retail clinics), eVisits <br /> INPATIENT HOSPITAL <br /> CARE <br /> Illness or injury 100 a 80%after deductible 100% after deductible 100 o after deductible <br /> Mental health care <br /> Chemical health care <br /> OUTPATIENT CARE <br /> Scheduled outpatient 100 o after$30 copay 80% after deductibte 100% after deductibte 100% after deductibte <br /> procadures <br /> Outpatient Magnetic 100%covera;e 80%after deductible 100% after deductible 100� after deductible <br /> Resonance Imaging <br /> (MRI)and Computing <br /> Tomography (CT) <br /> URGENT OREMERGENCY <br /> CARE <br /> Urgent care center 100�after$30 copay 80% after deductibte 1004o after deductible 100% after deductibte <br /> Hospital emergency 100%after$75 copay 80 o after deductible 100% after deductibl2 100% after deductible <br /> room <br /> Emergency ambulance 80 0 80qo after deductible 100% after deductible 100% after deductibte <br /> Emergency Services 75 o coverage of 15C 80%coverage after in- 100% after deductible HealthPartners in- <br /> from Non-Preferred $2,500 then 100% network deductibte network benefit <br /> Providers covera;e <br /> DURABLE MEDICAL ' <br /> EQUIPMENT AND 80% 80%after deductible 10oq after deductibte 100 o after deductible <br /> PROSTHETICS <br /> PRESCRIPTION <br /> MEDlCAT/ONS <br /> Up to o 31-day supply; or Retait Pharmacy- 80� Retail Pharmacy - 80% 80%coverage with the 100%coverage after <br /> 1 cyc(e of oro( coverage with the covera;e with the member responsible for deductible for all drugs <br /> contraceptives; ond up ! member responsib(e for member responsibEe for minimum payment of <br /> to o 93-day supply for '� minimum payment of$10 minimum payment of $10 and maximum of <br /> moi( order. Tobocco ' and maximum of$25 per 510 and maximum of 525 per prescription. <br /> cessation products are prescription. $25 per prescription. <br /> timited to coverage in- <br /> network and a 180 day I <br /> supply per year. i <br /> 090809 � <br />