Comprehensive major medical with deductible Benefits are effective October 1, 2010.

Plan Numbers: 118, 120, 121, 122, 123 Please note: Benefits are subject to regulatory approval

Plan highlights	In network	Out of network
Calendar-year deductible options Employers choose one of five options. One deductible applies to services from all providers.	$300/person – $900/family $500/person – $1,000/family $750/person – $1,500/family $1,000/person – $2,000/family $2,000/person – $4,000/family
Out-of-pocket maximum These options correspond to the deductible selected. A separate out-of-pocket maximum of $750 per person or $1,500 per family applies to prescription drugs.	$1,500/person – $5,000/family $1,800/person – $5,000/family $2,000/person – $5,000/family $2,250/person – $5,000/family $2,500/person – $5,000/family	$2,500/person $2,700/person $2,700/person $2,700/person $3,000/person
Lifetime maximum	Unlimited
Physician services • Office or urgent care visits for illness or injury • Retail health clinic • Behavioral health care (mental health, substance abuse, eating disorders and autism) • Chiropractic manipulation • In-office surgery/allergy-related services	100% after $25 copay or $30 copay 100% 100% after $25 copay or $30 copay* 100% after $25 copay or $30 copay* 80% after deductible	60% after deductible 60% after deductible 60% after deductible 60% after deductible from participating providers; no benefits for services from nonparticipating providers 60% after deductible
Preventive care • Well-child services and immunizations • Prenatal care • Routine physicals and eye exams • Cancer screenings	100% 100% 100% 100%	60% after deductible 60% after deductible 60% after deductible 60% after deductible
Lab services	80% after deductible	60% after deductible
X-ray and diagnostic imaging	80% after deductible	60% after deductible
In- and outpatient hospital services • Facility services (includes behavioral health care) • Professional services (includes behavioral health care)	80% after deductible* 80% after deductible*	60% after deductible 60% after deductible
Emergency care • Outpatient facility services • Outpatient professional services	100% after $100 copay 100%	100% after $100 copay 100%
Ambulance services	80%	80%
Medical supplies	80% after deductible	60% after deductible
Therapy services • Chiropractic therapy • Occupational and physical therapy • Speech therapy	80% after deductible* 80% after deductible 80% after deductible	60% after deductible from participating providers; no benefits for services from nonparticipating providers No coverage No coverage
Prescription drugs • Retail (31-day supply) • Specialty drugs • 90dayRx (90-day supply) excludes specialty drugs	$9 generic/$40 formulary brand/ $90 non-formulary brand 20% coinsurance to a maximum of $200 per specialty prescription $18 generic/$80 formulary brand/ $180 non-formulary brand	$9 generic/$40 formulary brand/ $90 non-formulary brand; member pays the pharmacy and files a claim. In addition to copays, member will be responsible for amounts in excess of allowed amount. No coverage
	If a generic drug is available and member chooses a brand-name drug, member pays the difference between the brand-name price and the generic price, plus any coinsurance. In some cases, this can amount to the full cost of the brand-name drug.
Health support included with your plan	Online Health Assessment and Coaching Modules • Health Guides and Nurse Guides • Dedicated Nurse Support • Fitness Program • Employee Assistance • 24-Hour Nurse Advice Line • Healthy Startฎ Prenatal Support • Stop-Smoking Support
Your out-of-pocket costs depend on the network status of your provider. To check status, call Blue Plus customer service at the number on the back of your member ID card or visit bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers (You are responsible for the difference between Blue Cross’ allowed amount and the amount billed by nonparticipating providers. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross’ allowed amount, which is typically lower than the amount billed by the provider.) This plan design does not comply with federal mental health parity regulations that are applicable to groups with 51 or more employees.