2014 health plans - ebview · swift big stone brown murray cottonwood pipe- stone lincoln rock...
TRANSCRIPT
2014 heALth PLAnSfor individuals and familiesOff-exchange plans
BlueAccess with the Awarereg network 2
BlueBasic with the Consumer Value network 12
BlueConnect Sanford Health with the Sanford health network 20
BluePrint by Blue Cross and Blue Shield of Minnesota and Allina Health with the Allina health network 26
BlueSave with the Consumer Value network 32
BlueValue with the Blue Performance Regional network 34
Please note plan highlights for MNsure plans may be downloaded and printed from Blue Edge
Table of conTenTs
DodgeSteele
RiceNicollet
Watonwan
RedwoodLyon
Yellow Medicine
Lac Qui Parle
RenvilleDakotaScott
Carver
Sibley
McLeod
HennepinRam- sey
Washington
AnokaWright
Sherburne
PopeStevensTraverse
Grant Douglas
Otter TailWilkin
Clay Becker
BentonStearns
MeekerKandiyohi
Chippewa
Swift
Big Stone
Brown
CottonwoodMurrayPipe- stone
Lincoln
Rock Nobles Jackson Martin Faribault
Blue EarthWaseca
Le Sueur
Olmsted
Wabasha
Lake of the Woods
Winona
Fillmore HoustonFreeborn Mower
Goodhue
Koochiching
Beltrami
HubbardCass
Aitkin
Pine
Crow Wing
Wadena
ToddMorrison
Mille Lacs
KanabecIsanti
Chisago
Roseau
St Louis
Carlton
Lake
Cook
Itasca
Norman Mahnomen
Clearwater
Polk
Red Lake
Pennington
Marshall
Kittson
BlueAccess BlueBasicBlueSaveInstaCare
BlueAccess BlueBasicBluePrintBlueSaveInstaCare
BlueAccessBlueValueInstaCare
BlueAccessBlueBasicBlueConnectBlueSaveInstaCareSM
FIND YOUR CLIENTrsquoS HEALTH PLAN
BlueAccess (Awarereg network) enjoy easy access to the most health care providers
BlueBasic (Consumer Value network) Get the basics in a lower-cost health plan
BlueConnect Sanford Health (Sanford health network) Benefit from a personalized approach that helps you achieve your best health
BluePrint by Blue Cross and Allina Health (Allina health network) Save with a smarter health plan and a more personalized experience
BlueSave (Consumer Value network) Our most affordable coverage for young adults
BlueValue (Blue PerformanceSM Regional network) have more control over your health care dollars
InstaCare (Blue Performance Regional network) Short-term coverage for 30 60 or 90 days
OUR HEALTH PLANS
Product maP for the individual and family markethealth plans are available for your clients based on where they live Our service areas cover the entire state of Minnesota Use this map to find the plans available in each service area
FIND A DOCTORneed to check if your clientrsquos doctor or hospital is in the network or tier 1 or tier 2 Visit bluecrossmncom and click ldquoFind a doctorrdquo
We feature a large network of health care providers each provider is an independent contractor and is not our agent
1
Subhead
BLUEACCESS HSA $3150$6300 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3150 per person $6300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$3150 per person $6300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical speech and occupational therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
2
CM0859 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADX) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
3
BLUEACCESS $0 non-embedded deductible and 10 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
10
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $5000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs 10 to a
maximum of $100 per prescription
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs No
coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $25 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
10 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $25 copay 50 after deductible is met
Emergency care $150 copay $150 copay
Maternity 10 (no deductible) 50 after deductible is met
4
CM0860 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
10 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
bull $200 copay per admission bull 10 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $25 copay per visit in the office bull 10 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $100 copay per visit in the office
bull 10 (no deductible) outpatient hospital
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
10 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE4) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
5
BLUEACCESS $0 non-embedded deductible and 20 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $30 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
20 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $30 copay 50 after deductible is met
Emergency care $200 copay $200 copay
6
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BlueAccess with the Awarereg network 2
BlueBasic with the Consumer Value network 12
BlueConnect Sanford Health with the Sanford health network 20
BluePrint by Blue Cross and Blue Shield of Minnesota and Allina Health with the Allina health network 26
BlueSave with the Consumer Value network 32
BlueValue with the Blue Performance Regional network 34
Please note plan highlights for MNsure plans may be downloaded and printed from Blue Edge
Table of conTenTs
DodgeSteele
RiceNicollet
Watonwan
RedwoodLyon
Yellow Medicine
Lac Qui Parle
RenvilleDakotaScott
Carver
Sibley
McLeod
HennepinRam- sey
Washington
AnokaWright
Sherburne
PopeStevensTraverse
Grant Douglas
Otter TailWilkin
Clay Becker
BentonStearns
MeekerKandiyohi
Chippewa
Swift
Big Stone
Brown
CottonwoodMurrayPipe- stone
Lincoln
Rock Nobles Jackson Martin Faribault
Blue EarthWaseca
Le Sueur
Olmsted
Wabasha
Lake of the Woods
Winona
Fillmore HoustonFreeborn Mower
Goodhue
Koochiching
Beltrami
HubbardCass
Aitkin
Pine
Crow Wing
Wadena
ToddMorrison
Mille Lacs
KanabecIsanti
Chisago
Roseau
St Louis
Carlton
Lake
Cook
Itasca
Norman Mahnomen
Clearwater
Polk
Red Lake
Pennington
Marshall
Kittson
BlueAccess BlueBasicBlueSaveInstaCare
BlueAccess BlueBasicBluePrintBlueSaveInstaCare
BlueAccessBlueValueInstaCare
BlueAccessBlueBasicBlueConnectBlueSaveInstaCareSM
FIND YOUR CLIENTrsquoS HEALTH PLAN
BlueAccess (Awarereg network) enjoy easy access to the most health care providers
BlueBasic (Consumer Value network) Get the basics in a lower-cost health plan
BlueConnect Sanford Health (Sanford health network) Benefit from a personalized approach that helps you achieve your best health
BluePrint by Blue Cross and Allina Health (Allina health network) Save with a smarter health plan and a more personalized experience
BlueSave (Consumer Value network) Our most affordable coverage for young adults
BlueValue (Blue PerformanceSM Regional network) have more control over your health care dollars
InstaCare (Blue Performance Regional network) Short-term coverage for 30 60 or 90 days
OUR HEALTH PLANS
Product maP for the individual and family markethealth plans are available for your clients based on where they live Our service areas cover the entire state of Minnesota Use this map to find the plans available in each service area
FIND A DOCTORneed to check if your clientrsquos doctor or hospital is in the network or tier 1 or tier 2 Visit bluecrossmncom and click ldquoFind a doctorrdquo
We feature a large network of health care providers each provider is an independent contractor and is not our agent
1
Subhead
BLUEACCESS HSA $3150$6300 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3150 per person $6300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$3150 per person $6300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical speech and occupational therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
2
CM0859 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADX) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
3
BLUEACCESS $0 non-embedded deductible and 10 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
10
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $5000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs 10 to a
maximum of $100 per prescription
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs No
coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $25 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
10 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $25 copay 50 after deductible is met
Emergency care $150 copay $150 copay
Maternity 10 (no deductible) 50 after deductible is met
4
CM0860 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
10 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
bull $200 copay per admission bull 10 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $25 copay per visit in the office bull 10 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $100 copay per visit in the office
bull 10 (no deductible) outpatient hospital
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
10 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE4) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
5
BLUEACCESS $0 non-embedded deductible and 20 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $30 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
20 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $30 copay 50 after deductible is met
Emergency care $200 copay $200 copay
6
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
DodgeSteele
RiceNicollet
Watonwan
RedwoodLyon
Yellow Medicine
Lac Qui Parle
RenvilleDakotaScott
Carver
Sibley
McLeod
HennepinRam- sey
Washington
AnokaWright
Sherburne
PopeStevensTraverse
Grant Douglas
Otter TailWilkin
Clay Becker
BentonStearns
MeekerKandiyohi
Chippewa
Swift
Big Stone
Brown
CottonwoodMurrayPipe- stone
Lincoln
Rock Nobles Jackson Martin Faribault
Blue EarthWaseca
Le Sueur
Olmsted
Wabasha
Lake of the Woods
Winona
Fillmore HoustonFreeborn Mower
Goodhue
Koochiching
Beltrami
HubbardCass
Aitkin
Pine
Crow Wing
Wadena
ToddMorrison
Mille Lacs
KanabecIsanti
Chisago
Roseau
St Louis
Carlton
Lake
Cook
Itasca
Norman Mahnomen
Clearwater
Polk
Red Lake
Pennington
Marshall
Kittson
BlueAccess BlueBasicBlueSaveInstaCare
BlueAccess BlueBasicBluePrintBlueSaveInstaCare
BlueAccessBlueValueInstaCare
BlueAccessBlueBasicBlueConnectBlueSaveInstaCareSM
FIND YOUR CLIENTrsquoS HEALTH PLAN
BlueAccess (Awarereg network) enjoy easy access to the most health care providers
BlueBasic (Consumer Value network) Get the basics in a lower-cost health plan
BlueConnect Sanford Health (Sanford health network) Benefit from a personalized approach that helps you achieve your best health
BluePrint by Blue Cross and Allina Health (Allina health network) Save with a smarter health plan and a more personalized experience
BlueSave (Consumer Value network) Our most affordable coverage for young adults
BlueValue (Blue PerformanceSM Regional network) have more control over your health care dollars
InstaCare (Blue Performance Regional network) Short-term coverage for 30 60 or 90 days
OUR HEALTH PLANS
Product maP for the individual and family markethealth plans are available for your clients based on where they live Our service areas cover the entire state of Minnesota Use this map to find the plans available in each service area
FIND A DOCTORneed to check if your clientrsquos doctor or hospital is in the network or tier 1 or tier 2 Visit bluecrossmncom and click ldquoFind a doctorrdquo
We feature a large network of health care providers each provider is an independent contractor and is not our agent
1
Subhead
BLUEACCESS HSA $3150$6300 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3150 per person $6300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$3150 per person $6300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical speech and occupational therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
2
CM0859 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADX) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
3
BLUEACCESS $0 non-embedded deductible and 10 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
10
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $5000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs 10 to a
maximum of $100 per prescription
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs No
coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $25 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
10 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $25 copay 50 after deductible is met
Emergency care $150 copay $150 copay
Maternity 10 (no deductible) 50 after deductible is met
4
CM0860 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
10 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
bull $200 copay per admission bull 10 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $25 copay per visit in the office bull 10 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $100 copay per visit in the office
bull 10 (no deductible) outpatient hospital
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
10 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE4) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
5
BLUEACCESS $0 non-embedded deductible and 20 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $30 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
20 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $30 copay 50 after deductible is met
Emergency care $200 copay $200 copay
6
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Subhead
BLUEACCESS HSA $3150$6300 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3150 per person $6300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$3150 per person $6300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical speech and occupational therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
2
CM0859 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADX) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
3
BLUEACCESS $0 non-embedded deductible and 10 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
10
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $5000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs 10 to a
maximum of $100 per prescription
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs No
coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $25 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
10 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $25 copay 50 after deductible is met
Emergency care $150 copay $150 copay
Maternity 10 (no deductible) 50 after deductible is met
4
CM0860 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
10 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
bull $200 copay per admission bull 10 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $25 copay per visit in the office bull 10 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $100 copay per visit in the office
bull 10 (no deductible) outpatient hospital
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
10 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE4) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
5
BLUEACCESS $0 non-embedded deductible and 20 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $30 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
20 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $30 copay 50 after deductible is met
Emergency care $200 copay $200 copay
6
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
CM0859 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADX) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
3
BLUEACCESS $0 non-embedded deductible and 10 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
10
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $5000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs 10 to a
maximum of $100 per prescription
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs No
coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $25 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
10 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $25 copay 50 after deductible is met
Emergency care $150 copay $150 copay
Maternity 10 (no deductible) 50 after deductible is met
4
CM0860 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
10 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
bull $200 copay per admission bull 10 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $25 copay per visit in the office bull 10 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $100 copay per visit in the office
bull 10 (no deductible) outpatient hospital
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
10 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE4) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
5
BLUEACCESS $0 non-embedded deductible and 20 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $30 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
20 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $30 copay 50 after deductible is met
Emergency care $200 copay $200 copay
6
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEACCESS $0 non-embedded deductible and 10 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
10
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $5000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs 10 to a
maximum of $100 per prescription
bull Preferred generic $5 copay bull Preferred brand $15 copay bull Non-preferred $50 copay bull Specialty drugs No
coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $25 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
10 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $25 copay 50 after deductible is met
Emergency care $150 copay $150 copay
Maternity 10 (no deductible) 50 after deductible is met
4
CM0860 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
10 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
bull $200 copay per admission bull 10 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $25 copay per visit in the office bull 10 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $100 copay per visit in the office
bull 10 (no deductible) outpatient hospital
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
10 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE4) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
5
BLUEACCESS $0 non-embedded deductible and 20 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $30 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
20 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $30 copay 50 after deductible is met
Emergency care $200 copay $200 copay
6
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
CM0860 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
10 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
bull $200 copay per admission bull 10 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $25 copay per visit in the office bull 10 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $100 copay per visit in the office
bull 10 (no deductible) outpatient hospital
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
10 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE4) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
5
BLUEACCESS $0 non-embedded deductible and 20 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $30 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
20 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $30 copay 50 after deductible is met
Emergency care $200 copay $200 copay
6
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEACCESS $0 non-embedded deductible and 20 coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$0 per person $0 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
bull $30 copay
bull $50 copay
50 after deductible is met
Chiropractic physical speech and occupational therapy
20 (no deductible)
50 after deductible is met
Online Care Anywherereg e-visit Two free visits then $30 copay 50 after deductible is met
Emergency care $200 copay $200 copay
6
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
CM0861 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Maternity 20 (no deductible) 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 (no deductible)
50 after deductible is met
Diagnostic tests (X-rays blood work) bull $30 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
bull $500 copay per visit in the office bull 20 (no deductible) outpatient
hospital 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 (no deductible) 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE3) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
7
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEACCESS HSA $1800$3600 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1800 per person $3600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1800 per person $3600 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
8
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
CM0862 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE1) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
9
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEACCESS HSA $5200$10400 non-embedded deductible and no coinsurance For individuals and families Awarereg network Your costs In Aware network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5200 per person $10400 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5200 per person $10400 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met
50 after deductible is met
Online Care Anywherereg e-visit 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
10
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
CM0863 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Aware network Out of network Hospital visit (outpatient)
bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE5) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
11
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEBASIC $2200$4400 deductible and 20 coinsurance For individuals and families Consumer Valuereg network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
Your costs
$2200 per person $4400 per family
In Consumer Value network
$10000 per person $20000 per family
Out of network
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-ofshypocket maximum
Key benefits Includes care for mental health and substance abuse
$5650 per person $11300 per family
You pay
In Consumer Value network
unlimited
Out of network
Prescription drugs Preferred drugs are on the GenRx drug list
Preventive caretests
Prenatal and well-child care bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
0 (no deductible)
0 (no deductible)
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
50 after deductible is met
0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull $45 copay bull $65 copay
50 after deductible is met
Chiropractic physical occupationaland speech therapy 20 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit
Emergency care
Two free visits then $45 copay
20 after deductible is met
50 after deductible is met
20 after deductible is met
12
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE9)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0864 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
13
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEBASIC $3300$6600 deductible and 50 coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$3300 per person $6600 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 50 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
50 after deductible is met 50 after deductible is met
Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
50 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 50 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 50 after deductible is met 50 after deductible is met
Emergency care 50 after deductible is met 50 after deductible is met
Maternity 50 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
14
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
50 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 50 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
50 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
50 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE7)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0865 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
15
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEBASIC $4350$8700 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$4350 per person $8700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$4350 per person $8700 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Generic $15 copay bull All brand drugs 0 after
deductible is met
bull Generic $15 copay bull All brand drugs 0 after
deductible is met Visits to bull Health care providerrsquos office
retail health clinic or urgent care clinic
bull Specialist
Two free visits then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupationaland speech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
16
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAEA)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0866 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
17
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEBASIC $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible 0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family unlimited
Key benefits Includes care for mental health and substance abuse
You pay In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list 0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
One free visit then 0 after deductible is met 50 after deductible is met
Chiropractic physical occupational andspeech therapy 0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
18
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits You pay Includes care for mental health and substance abuse In Consumer Value network Out of network
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children for one pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AAE8)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0867 (713) Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
19
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUECONNECT $1000$3000 deductible and 0 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network Out of network Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family unlimited
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational andspeech therapies
bull Three free visits then 0 after deductible is met bull 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
20
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits You pay Includes care for mental health and substance abuse In Sanford Health network Out of network
Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met 50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADL)Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1shy800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0868 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 21
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUECONNECT $1500$4500 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Two free visits then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies
20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
22
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADJ) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov
CM0869 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensee s of the Blue Cross and Blue Shield Association
23
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUECONNECT $1900$5700 deductible and 20 coinsurance For individuals and families Sanford Health network Your costs In Sanford Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 50 after deductible is met
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay
bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
bull One free visit then 20
after deductible is met 50 after deductible is met
Chiropractic physical occupational and speech therapies 20 after deductible is met 50 after deductible is met
Emergency care
20 after deductible is met
20 after deductible is met
24
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network Out of network Chronic condition package Coverage of selected services for diabetes and high blood pressure
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADG) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0870 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
25
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEPRINT $1000$3000 deductible and 0 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1000 per person $3000 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$1000 per person $3000 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 0 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 0 after deductible is met 50 after deductible is met
Emergency care 0 after deductible is met
0 after deductible is met
26
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADT) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0871 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
27
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEPRINT $1500$4500 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1500 per person $4500 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$2500 per person $7500 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $10 copay bull Preferred brand $50 copay bull Non-preferred $90 copay bull Specialty drugs No
coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20
after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met 50 after deductible is met
28
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Emergency care 20 after deductible is met 20 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADR) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco
To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0872 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
29
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEPRINT $1900$5700 deductible and 20 coinsurance For individuals and families Allina Health network Your costs In Allina Health network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$1900 per person $5700 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs 20 to a
maximum of $200 per prescription
bull Preferred generic $15 copay bull Preferred brand $60 copay bull Non-preferred $90 copay bull Specialty drugs No coverage
Prescription drugs for chronic conditions Preferred drugs on the GenRx list for diabetes high blood pressure high cholesterol quitting tobacco and for diabetic supplies
$0 (no deductible) $0 (no deductible)
Visits to bull Health care providerrsquos office retail
health clinic urgent care clinic e-visits or telephone visits
bull Specialist
Two free visits then 20 after
deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy 20 after deductible is met 50 after deductible is met
30
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Emergency care 20 after deductible is met 20 after deductible is met
Chronic condition package Coverage of selected services for diabetes high blood pressure and high cholesterol
0 (no deductible) 50 after deductible is met
Maternity 20 after deductible is met 50 after deductible is met
Hospital visit (outpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
20 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 20 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans) 20 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
20 after deductible is met 50 after deductible is met
Dental for children For members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADP) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0873 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
31
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Subhead
BLUESAVE $5650$11300 deductible and no coinsurance For individuals and families Consumer Valuereg network Your costs In Consumer Value network
Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply in network
$5650 per person $11300 per family
$10000 per person $20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
0
50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply in network
$5650 per person
$11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Consumer Value network Out of network
Preventive caretests 0 (no deductible) 50 after deductible is met
Prenatal and well-child care
0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
0 after deductible is met 0 after deductible is met
Visits to bull Health care providerrsquos office retail
health clinic or urgent care clinic bull Specialist
Three free visits then 0 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
0 after deductible is met 50 after deductible is met
Online Care Anywherereg e-visit Two free visits then 0 after deductible is met
50 after deductible is met
Emergency care 0 after deductible is met 0 after deductible is met
Maternity 0 after deductible is met 50 after deductible is met
32
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Key benefits Includes care for mental health and substance abuse
You pay
In Allina Health network Out of network
Hospital visit (outpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Hospital stay (inpatient) bull Facility bull Physician
0 after deductible is met
50 after deductible is met
Diagnostic tests (X-rays blood work) 0 after deductible is met 50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
0 after deductible is met 50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members age 18 and under
0 after deductible is met 50 after deductible is met
Dental for children for members age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADW) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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 If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free) For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech) Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0874 (713)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association 33
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
BLUEVALUE $2400$4800 deductible and 20 coinsurance For individuals and families Blue Performance Regional network
Your costs In Blue Performance Regional network
In Aware network Out of network
Your deductible What you pay for covered health care services each calendar year before your health plan starts to pay Amounts paid out of network DO NOT apply to the in-network deductible
$2400 per person $4800 per family
$10000 per person
$20000 per family
Your coinsurance The percent you pay for your covered health care services after you meet your deductible
20 40 50
Your out-of-pocket maximum The maximum amount you pay per calendar year in deductibles coinsurance and copays Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum
$5650 per person $11300 per family
unlimited
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Preventive caretests 0 (no deductible) 0 (no deductible) 50 after deductible is
met
Prenatal and well-child care 0 (no deductible) 0 (no deductible) 0 (no deductible)
Prescription drugs Preferred drugs are on the GenRx drug list
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs 20 to a maximum of $200 per prescription
Preferred generic $10 copay
Preferred brand $50 copay
Non-preferred $90 copay
Specialty drugs no coverage
Visits to Health care providerrsquos
office retail health clinic or urgent care clinic
Specialist
Two free visits then 20 after deductible is
met
40 after deductible is met
50 after deductible is met
Chiropractic physical occupational and speech therapy
20 after deductible is met
40 after deductible is met
50 after deductible is met
Emergency care 20 after deductible is met
20 after deductible is met
20 after deductible is met
34
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
Key benefits Includes care for mental health and substance abuse
You pay
In Sanford Health network
In Aware network Out of network
Hospital visit (outpatient) Facility Physician
20 after deductible is
met
40 after deductible is
met
50 after deductible is
met
Hospital stay (inpatient) Facility Physician
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Diagnostic tests (X-rays blood work)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Imaging tests (for example MRIs CT or CAT scans PET scans)
20 after deductible is met
40 after deductible is met
50 after deductible is met
Eyewear for children One pair of lenses and one pair of frames for members under age 18 and under
20 after deductible is
met
40 after deductible is met
50 after deductible is
met
Dental for children For members under age 18 and under
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
This coverage is required but you may opt out if you have dental coverage certified by MNsure
For January 1 2014 to December 31 2014 (AADV) Your out-of-pocket costs for most services depend on the network status of your health care provider To check provider status use the ldquoFind a doctorrdquo web tool on bluecrossmncom 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
If you receive services from a nonparticipating provider you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills This difference does not apply to your out-of-pocket maximum This is in addition to any applicable deductible copay or coinsurance Benefit payments are calculated on Blue Crossrsquo allowed amount which is typically lower than the amount billed by the provider
This is only a summary Your contract will provide a detailed description of what is and is not covered Services not covered include custodial care or rest cures bariatric surgery infertility adult eyewear adult dental services services that are experimental not medically necessary or received while on military duty and certain services for the treatment of autism
This information is also available in other ways to people with disabilities by calling customer service at (651) 662-5040 (voice) or 1-800-711-9875 (toll free)
For (TTY) call (651) 662-8700 or 1-888-878-0137 (TTY) or 711 or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY Voice ASCII Hearing Carry Over) or 1-877-627-3848 (Speech-to-Speech)
Hours 8 am to 5 pm Central Time Monday through Thursday 9 am to 5 pm Central Time Friday
Attention If you want free help translating this information call the above number Atencion Si desea recibir asistencia gratuita para traduca esta informacion llame al numero que aparece mas arriba
Blue Cross may change premium rates on an annual renewal date when you add or delete a dependent or if you move to a different Blue Cross plan Factors that may affect changes in premium rates include the age of covered members where you reside and whether a member uses tobacco To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you please go to healthcaregov CM0875 (713)
35
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
notes
36
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us
bluecrossmncom
X18896R02 (913)
Blue Crossreg and Blue Shieldreg of Minnesota and Blue Plusreg are nonprofit independent licensees of the Blue Cross and Blue Shield Association
As Minnesotarsquos health care leader we live fearless We believe good health is for
everyone mdash not just our members Itrsquos a big vision And thatrsquos why wersquore investing in
the communities we serve and empowering individuals to make smart choices about
their health Live fearless with the peace of mind that comes from knowing yoursquore
protected by the strength and stability of Blue Cross We invite you to join us