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JANUARY 1, 2010 <br /> CITY OF ORONO (LOGIS) HEALTH CARE PLANS COMPARISON <br /> Open Access, Distinctions, $2500 HDHP/HRA and $2500 HDHP/HSA <br /> -- ,•;�.,� � = , °.� �- - <br /> . ,• ; <br /> , <br /> � ,� � � � .�- . �: � '� � r �, �. �;��. . - r <br /> �.: _�' �; ��_`; f,-. <br /> i.� �*�-� �:�r ,��� - ' " : y� .� t i _.�� - <br /> i �, E` �: yw <br /> i .' �'' f� : - . <br /> .k -�`. <br /> ; RA TES ' � <br /> � Single $ 666.76 5 596.34 $472.00 5 439.76 <br /> Employee + Spouse 51418.74 $1268.78 $1006.62 S 937.76 <br /> Employee +Child(ren) $1344.22 $1202.14 5 951.02 $ 885.96 <br /> Family $1755.50 51569.90 51241.92 51156.96 <br /> t In-Network Benefits In-Network Benefits In-Network Benefits In-Network Benefits <br /> When care is provided by When care is provided When care is provided When care is provided <br /> a network provider by a network provider by a network provider by a network provider <br /> Lifetime Moximum Untimited Unlimited Unlimited Unlimited <br /> Benefit <br /> Out of Pocket Maximum ( <br /> (Colendar Yeor) <br /> Single S1,200 per person 51,500 per person $4,000 per person $2,500 per person (in- <br /> � (in-network only) (in-network only) (in-network only) network onty) <br /> Family 55,000 per family $3,000 per family 58,000 per family 55,000 per family (in- <br /> (in-network only) (in-network onty) (in-network only) network onty) <br /> Each family member moy <br /> receive up[o a combined <br /> tota(of three office <br /> visits, convenience care <br /> and urgent care visrts <br /> each year where the <br /> physician's services Qre <br /> covered at 100`6. Afl <br /> charges for office <br /> Iprocedures, faboratory, <br /> radiology, dcy treatment <br /> services, group visits, <br /> chiropractic care, <br /> pAysical, occupational, & <br /> speech therapy services <br /> are subject to the <br /> deductib(e&coinsurance. <br /> Deductib(e <br /> Singfe None $S00 per person $2,500 per person $2,500 per person (in- <br /> , (in-network onty) (in-network only� network only) <br /> Family None $1,000 per family 55,000 per family 55,000 per family (in- <br /> , (in-network only) (in-network only) network onty) <br /> When you receive � When you receive When you receive I When you receive <br /> covered services, covered services, covered services, covered services, <br /> , HealthPartners PAYS: HealthPartners PAYS: HeatthPartners PAYS: HealthPartners PAYS: <br /> PREVENTIVE HEALTH <br /> CARE <br /> Routine physical exams 100q 100% Deductibte does 100% Deductible does 100% Deductible does <br /> Et eye examinations not apply. not apply not apply <br /> Prenatat 8 postnatal 100% 100% Deductib[e does 100% Deductible does no 1�� Deductible does <br /> care, well-child care not apply. apply not apply <br /> Immunizations 100% 100% Deductible does 100� Deductible does 100% Deductible does <br /> not appty. not appty not apply <br /> OFFICE VISITS <br /> Itiness or Injury 100%after$30 copay 80� after deductible 100A after deductib[e 100w after deductible <br /> Atlergy injections 100%coverage 100% Deductible does 100� Deductibte does 100% after deductible <br /> � not apply not apply <br /> � <br /> o9oso� 1 <br />