YOUR LIFE. YOUR CHOICE. YOUR HEALTH PLAN. Leave school with health plan coverage Exclusive offer for students previously enrolled in the University of Minnesota-sponsored student health benefit plan Rates effective January 1, 2015 through December 31, 2015
CHOOSE THE PLAN THAT MAKES IT EASY TO GO WHERE LIFE TAKES YOU You re ready for the next stage in your life. You have a lot of exciting opportunities: moving, a new academic challenge or finding a job. The last thing you want to worry about is a gap in your health coverage. Your student health plan will end soon. Without coverage, you could be vulnerable. NEw HEALTH LAw. NO worries. Now that you are choosing a new health plan, you ll want one that meets requirements of health care overhaul laws. The Affordable Care Act requires everyone to have a qualified plan or face tax penalties. When you choose one of the Blue Cross health plans in this guide, you will not have to worry about tax penalties. TRAVEL with CONFIDENCE Plan on traveling? Or are you an out -of- state student? No problem. All of our health plans come with the BlueCard PPO network. That means you re covered at more than 92 percent of doctors and 96 percent of hospitals nationwide. You also get access to doctors and hospitals in more than 200 countries with BlueCard Worldwide.
PERSONALIzEd ONLINE ACCESS Your time is valuable. Blue Cross makes it easy to find information to take care of your health. Tools are available to you online 24 hours a day, seven days a week. Get health and wellness tips, learn how to manage health conditions or find a doctor. Visit mybluecrossmn.com to register. MObILE CONVENIENCE When you re on the go, you can tap into your health benefits with the BlueCrossMN mobile app. The app is available for Apple and Android devices. With a touch of a screen, you can look up your member information, find out what s covered, get access to health discounts and more. Finding a doctor, clinic or hospital near you is quick and convenient. Members can register at mybluecrossmn.com to download the app. save TIME AND MONEY with THE FIND A DOCTOR TOOL It s easy to compare doctors and shop for the best price on care with the Find a doctor web tool. It offers many advanced features: Choose a doctor, hospital, urgent care center or convenience clinic in your plan s network Compare health care providers based on cost and quality ratings See estimated total costs and your estimated out-of-pocket expense for more than 300 common procedures Read other consumers reviews of doctors and write your own DID YOU know? You ll get a personalized online account to: Keep track of your claims Manage your accounts Find doctors Get health information and more 1
TOOLS For your HEALTH ANd WELLBEING The best time to think about your health is before you get sick. It s about taking time for your health every day so you stay well. The chart below lists tools and resources that are included in your health plan. These tools can help you take charge of your health habits. Choose the options that best meet your health goals and desired approach. legend Health Habits Managing Stress Eating Right Staying Active Managing Weight Quitting Tobacco Maintaining a Healthy Pregnancy Making Health Decisions GEt well Options Description Health Habits Contact Online Care Meet face-to-face with a board-certified doctor online, from home or work or even on vacation with Online Care Anywhere. onlinecareanywheremn.com Nurse Line Talk to a nurse 24 hours a day, 7 days a week to help you get answers to your health-related questions. 1-800-622-9524 Provider Cost/ Quality Care Coordination Get recommendations on doctors, hospitals, prescriptions and other information, based on cost and quality. Talk with a nurse, social worker or other health professional about managing your (or your family member s) complex health care needs. mybluecrossmn.com Number on the back of your member ID card SAVE MONEY Options Description Health Habits Contact Fitness Membership Discount Online Marketplace Vacation Savings Program Get a $20 discount for working out 12 days per month at a participating fitness center. Get exclusive savings on health and wellbeing products and services not typically covered by plan with CareXtend. Start saving for your next vacation and receive a 50 percent matching credit with the Adestinn vacation savings program. mybluecrossmn.com CareXtend.com adestinn.com 2
FIND ANSwERS Options Description Health Habits Contact Health Guides Online Health Assessment Online Health and Wellbeing Resources Get answers to your questions about your health plan benefits or get connected to a nurse for questions about your health. Answer questions that assess your health history and health behaviors to get a snapshot of your current health status. Access a library of articles, videos, quizzes and calculators about health conditions, diseases, procedures and prescriptions. Number on the back of your member ID card bluecrossmn.com/ myhealth bluecrossmn.com/ healthandwellness SEEK SUPPORt Options Description Health Habits Contact Online Health Coaching Stop Smoking Support Chronic Condition Management Provides personalized online coaching to help address your health goals and concerns. Helps you develop and maintain a quit plan with information and support from a Quit Coach. Includes over-thecounter medications to help you quit. Get support from a nurse about managing your chronic condition(s), such as diabetes, cancer or asthma. bluecrossmn.com/ healthandwellness 1-888-662-2583 or mybluecrossmn.com Number on the back of your member ID card 3
blue CROss HEALTH PLANs HEALTH COVERAgE FOR AN ACTIVE LIFEsTYLE BlueAccess with the Aware network Enjoy easy access to the most health care providers BlueAccess plans come with the convenience of our biggest and broadest network, which includes 100 percent of hospitals and 98 percent of doctors in Minnesota. Boynton Health Services and University of Minnesota Physicians are in the Aware network. Some BlueAccess plans also let you add a health savings account (HSA). HSAs help you save tax-free money, earn interest on that money and use it to pay for medical expenses. This gives you confidence that wherever you go, Blue Cross is there. LOOk UP YOUR MONTHLY RATE Use the rating area map to determine the correct rating area based on where you live Find the appropriate rating area for the plan you want in this book Look up rates for you, your spouse and your dependents based on their age For dependents ages 21 to 25, assign a rate based on age For dependents ages 0 to 20, assign the flat rate with a limit, or cap, on three dependents. That means families with four or more dependents should only be charged for three of the child dependents. 4
RATING AREA MAP kittson Roseau Lake of the woods Marshall koochiching Pennington Red Lake beltrami Cook Polk Clearwater Itasca st. Louis Lake Norman Mahnomen Hubbard Clay becker Cass wilkin Otter Tail wadena Crow wing Aitkin Carlton grant Douglas Todd Morrison Mille Lacs kanabec Pine Traverse big stone stevens Pope stearns benton sherburne Isanti Chisago Lac Qui Parle Yellow Medicine Lincoln Ramsey Pipestone Lyon Murray swift Chippewa Redwood Cottonwood kandiyohi Renville brown Meeker watonwan McLeod sibley Nicollet wright blue Earth Carver Hennepin Le sueur scott waseca Anoka Rice steele Dakota washington goodhue Dodge wabasha Olmsted winona Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston 1 2 3 4 Dodge, Fillmore, Freeborn, Goodhue, Houston, Mower, Olmsted, Steele, Wabasha, Winona counties and outside of Minnesota Carlton, Cook, Itasca, Koochiching, Lake, Lake of the Woods, St. Louis counties Blue Earth, Faribault, Waseca, Le Sueur, Martin, Nicollet, Rice, Watonwan counties Brown, Cottonwood, Jackson, Lincoln, Murray, Nobles, Pipestone, Redwood, Rock counties 6 7 8 9 Becker, Clay, Douglas, Grant, Otter Tail, Pope, Stevens, Traverse, Wilkin counties Aitkin, Beltrami, Cass, Chisago, Crow Wing, Hubbard, Isanti, Kanabec, Mille Lacs, Morrison, Pine, Roseau, Todd, Wadena counties Anoka, Benton, Carver, Dakota, Hennepin, Ramsey, Scott, Sherburne, Stearns, Washington, Wright counties Clearwater, Kittson, Mahnomen, Marshall, Norman, Pennington, Polk, Red Lake counties 5 Big Stone, Chippewa, Kandiyohi, Lac Qui Parle, Lyon, McLeod, Meeker, Renville, Sibley, Swift, Yellow Medicine counties 5
BlueAccess HSA Bronze $4,500 Plan 235 Aware network Benefit highlights for individuals and families January 1, 2015 December 31, 2015 Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Non-embedded: The plan begins paying benefits that require cost sharing when the entire family deductible is met. The deductible can be met by one or a combination of several family members. The single deductible applies to single coverage only. Your coinsurance The percent you pay after your deductible is met. Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles and coinsurance. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum. Non-embedded: The family plan begins paying benefits when the entire family out-of-pocket is met. The out-ofpocket can be met by one or a combination of several family members. The single out-of-pocket applies to single coverage only. Visits to: health care provider s office specialist retail health clinic urgent care e-visits (Online Care Anywhere ) $4,500 single $9,000 family 0% 50% $4,500 single $9,000 family 0%after deductible $10,000 single $20,000 family Unlimited Other professional services in the office lab and diagnostic imaging/x-ray services Prescription drugs GenRx with open formulary Preventive care (including vision exam) 0% (no deductible) Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) Emergency care Ambulance Ambulatory surgical center Hospital (outpatient) lab and diagnostic imaging/x-ray services Hospital visit (inpatient) Chiropractic, physical, occupational and speech therapy Eyewear for children ages 18 and under lenses and one pair of frames or contact lenses 6
Your out-of-pocket costs depend on the network status of your provider. To check status, use the Find a doctor web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free). For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carry over), or 1-877-627-3848 (speech-to-speech). Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday. Attention. If you want free help translating this information, call the above number. Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba. Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco. To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov. YD501, YDU51 AASX X20363 (8/14) 7
BlueAccess HSA Bronze $5,200 Plan 236 Aware network Benefit highlights for individuals and families January 1, 2015 December 31, 2015 Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Non-embedded: The plan begins paying benefits that require cost sharing when the entire family deductible is met. The deductible can be met by one or a combination of several family members. The single deductible applies to single coverage only. Your coinsurance The percent you pay after your deductible is met. Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles and coinsurance. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum. Non-embedded: The family plan begins paying benefits when the entire family out-of-pocket is met. The out-ofpocket can be met by one or a combination of several family members. The single out-of-pocket applies to single coverage only. Visits to: health care provider s office specialist retail health clinic urgent care e-visits (Online Care Anywhere ) $5,200 single $10,400 family 0% 50% $5,200 single $10,400 family $10,000 single $20,000 family Unlimited Other professional services in the office lab and diagnostic imaging/x-ray services Prescription drugs GenRx with open formulary Preventive care (including vision exam) 0% (no deductible) Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) Emergency care Ambulance Ambulatory surgical center Hospital (outpatient) lab and diagnostic imaging/x-ray services Hospital visit (inpatient) Chiropractic, physical, occupational and speech therapy Eyewear for children ages 18 and under lenses and one pair of frames or contact lenses 8
Your out-of-pocket costs depend on the network status of your provider. To check status, use the Find a doctor web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free). For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carry over), or 1-877-627-3848 (speech-to-speech). Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday. Attention. If you want free help translating this information, call the above number. Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba. Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco. To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov. YD001, YDU01 AAT3 F10220R02 (8/14) 9
BlueAccess Silver $1,500 Plan 237 Aware network Benefit highlights for individuals and families January 1, 2015 December 31, 2015 Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible. Your coinsurance The percent you pay after your deductible is met. Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles, coinsurance and copays. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum Visits to: health care provider s office specialist retail health clinic urgent care e-visits (Online Care Anywhere ) $1,500 per person $3,000 family 40% 50% $6,000 per person $12,000 family $40 copay $60 copay $40 copay $40 copay First 3 visits free (no deductible), then $40 copay $10,000 per person $20,000 family Unlimited Other professional services in the office lab and diagnostic imaging/x-ray services 4 Prescription drugs GenRx with open formulary Preferred generic: $10 copay Preferred brand: $50 copay Non-preferred: $90 copay Specialty: 20% to a maximum of $200 per prescription Preferred generic: $10 copay Preferred brand: $50 copay Non-preferred: $90 copay Specialty: No coverage Preventive care (including vision exam) 0% (no deductible) Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) 4 Emergency care 4 4 4 4 Ambulance 4 4 Ambulatory surgical center 4 Hospital (outpatient) lab and diagnostic imaging/x-ray services Hospital visit (inpatient) Chiropractic, physical, occupational and speech therapy 4 4 4 4 4 4 Eyewear for children ages 18 and under lenses and one pair of frames or contact lenses 4 10
Your out-of-pocket costs depend on the network status of your provider. To check status, use the Find a doctor web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free). For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carry over), or 1-877-627-3848 (speech-to-speech). Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday. Attention. If you want free help translating this information, call the above number. Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba. Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco. To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov. YD502, YDU52 AATW X20364 (8/14) 11
BlueAccess HSA Silver $2,000 Plan 238 Aware network Benefit highlights for individuals and families January 1, 2015 December 31, 2015 Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Non-embedded: The plan begins paying benefits that require cost sharing when the entire family deductible is met. The deductible can be met by one or a combination of several family members. The single deductible applies to single coverage only. Your coinsurance The percent you pay after your deductible is met. Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles and coinsurance. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum. The single out-of pocket-maximum applies to single coverage only. Non-embedded: The family plan begins paying benefits when the entire family out-of-pocket is met. The out-ofpocket can be met by one or a combination of several family members. The single out-of-pocket applies to single coverage only. Visits to: health care provider s office specialist retail health clinic urgent care e-visits (Online Care Anywhere ) $2,000 single $4,000 family 20% 50% $4,000 single $8,000 family 2 2 2 2 2 $10,000 single $20,000 family Unlimited Other professional services in the office lab and diagnostic imaging/x-ray services 2 Prescription drugs 2 2 GenRx with open formulary Preventive care (including vision exam) 0% (no deductible) Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) 2 Emergency care 2 2 2 2 Ambulance 2 2 Ambulatory surgical center 2 Hospital (outpatient) lab and diagnostic imaging/x-ray services Hospital visit (inpatient) Chiropractic, physical, occupational and speech therapy 2 2 2 2 2 2 Eyewear for children ages 18 and under lenses and one pair of frames or contact lenses 2 12
Your out-of-pocket costs depend on the network status of your provider. To check status, use the Find a doctor web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free). For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carry over), or 1-877-627-3848 (speech-to-speech). Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday. Attention. If you want free help translating this information, call the above number. Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba. Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco. To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov. YD503, YDU53 AATS X20365 (8/14) 13
BlueAccess HSA Silver $3,000 Plan 239 Aware network Benefit highlights for individuals and families January 1, 2015 December 31, 2015 Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Embedded: The plan begins paying benefits that require cost sharing for the first family member who meets the perperson deductible. The family deductible must then be met by one or more of the remaining family members and then the plan pays benefits for all covered family members Your coinsurance The percent you pay after your deductible is met. Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles and coinsurance. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum Visits to: health care provider s office specialist retail health clinic urgent care e-visits (Online Care Anywhere ) $3,000 per person $6,000 family 0% 50% $3,000 per person $6,000 family $10,000 per person $20,000 family Unlimited Other professional services in the office lab and diagnostic imaging/x-ray services Prescription drugs GenRx with open formulary Preventive care (including vision exam) 0% (no deductible) Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) Emergency care Ambulance Ambulatory surgical center Hospital (outpatient) lab and diagnostic imaging/x-ray services Hospital visit (inpatient) Chiropractic, physical, occupational and speech therapy Eyewear for children ages 18 and under lenses and one pair of frames or contact lenses 14
Your out-of-pocket costs depend on the network status of your provider. To check status, use the Find a doctor web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free). For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carry over), or 1-877-627-3848 (speech-to-speech). Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday. Attention. If you want free help translating this information, call the above number. Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba. Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco. To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov. YD504, YDU54 AATP X20366 (8/14) 15
BlueAccess HSA Gold $1,800 Plan 240 Aware network Benefit highlights for individuals and families January 1, 2015 December 31, 2015 Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Non-embedded: The plan begins paying benefits that require cost sharing when the entire family deductible is met. The deductible can be met by one or a combination of several family members. The single deductible applies to single coverage only. Your coinsurance The percent you pay after your deductible is met. Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles and coinsurance. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum. Non-embedded: The family plan begins paying benefits when the entire family out-of-pocket is met. The out-ofpocket can be met by one or a combination of several family members. The single out-of-pocket applies to single coverage only. Visits to: health care provider s office specialist retail health clinic urgent care e-visits (Online Care Anywhere ) $1,800 single $3,600 family 0% 50% $1,800 single $3,600 family $10,000 single $20,000 family Unlimited Other professional services in the office lab and diagnostic imaging/x-ray services Prescription drugs GenRx with open formulary Preventive care (including vision exam) 0% (no deductible) Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) Emergency care Ambulance Ambulatory surgical center Hospital (outpatient) lab and diagnostic imaging/x-ray services Hospital visit (inpatient) Chiropractic, physical, occupational and speech therapy Eyewear for children ages 18 and under lenses and one pair of frames or contact lenses 16
Your out-of-pocket costs depend on the network status of your provider. To check status, use the Find a doctor web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free). For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carry over), or 1-877-627-3848 (speech-to-speech). Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday. Attention. If you want free help translating this information, call the above number. Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba. Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco. To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov. YD003, YDU55 AASN F10219R02 (8/14) 17
BlueAccess Gold No Deductible Plan 241 Aware network Benefit highlights for individuals and families January 1, 2015 December 31, 2015 Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Your coinsurance The percent you pay after your deductible is met. Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles, coinsurance, and copays. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum Visits to: health care provider s office specialist retail health clinic urgent care e-visits (Online Care Anywhere ) $0 per person $0 family 20% 50% $6,000 per person $12,000 family $30 copay $50 copay $30 copay $30 copay First 3 visits free (no copay), then $30 copay $10,000 per person $20,000 family Unlimited Other professional services in the office lab and diagnostic imaging/x-ray services 20% (no deductible) Prescription drugs GenRx with open formulary Preferred generic: $15 copay Preferred brand: $50 copay Non-preferred: $90 copay Specialty: 20% to a maximum of $200 per prescription Preferred generic: $15 copay Preferred brand: $50 copay Non-preferred: $90 copay Specialty: No coverage Preventive care (including vision exam) 0% (no deductible) Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) 20% (no deductible) Emergency care 0% (no deductible) $200 copay 0% (no deductible) $200 copay Ambulance 20% (no deductible) 20% (no deductible) Ambulatory surgical center 20% (no deductible) Hospital (outpatient) lab and diagnostic imaging/x-ray services Hospital visit (inpatient) Chiropractic, physical, occupational and speech therapy 20% (no deductible) 20% (no deductible) 20% (no deductible) 20% (no deductible) 20% (no deductible) 20% (no deductible) Eyewear for children ages 18 and under lenses and one pair of frames or contact lenses 20% (no deductible) 18
Your out-of-pocket costs depend on the network status of your provider. To check status, use the Find a doctor web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free). For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carry over), or 1-877-627-3848 (speech-to-speech). Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday. Attention. If you want free help translating this information, call the above number. Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba. Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco. To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov. YD002, YDU02 AASQ F10218R02 (8/14) 19
BlueAccess Platinum No Deductible Plan 242 Aware network Benefit highlights for individuals and families January 1, 2015 December 31, 2015 Key benefits In network Out of network Your deductible The amount you pay per calendar year before your health plan starts to pay. Amounts paid out of network DO NOT apply to the in-network deductible Your coinsurance The percent you pay after your deductible is met. Your out-of-pocket maximum The maximum amount you pay per calendar year in medical and prescription drug deductibles, coinsurance, and copays. Amounts paid out of network DO NOT apply to the in-network out-of-pocket maximum Visits to: health care provider s office specialist retail health clinic urgent care e-visits (Online Care Anywhere ) $0 per person $0 family 10% 50% $2,500 per person $5,000 family $20 copay $40 copay $20 copay $20 copay First 3 visits free (no copay), then $20 copay $10,000 per person $20,000 family Unlimited Other professional services in the office lab and diagnostic imaging/x-ray services 10% (no deductible) Prescription drugs GenRx with open formulary Preferred generic: $5 copay Preferred brand: $15 copay Non-preferred: $50 copay Specialty: 10% to a maximum of $100 per prescription Preferred generic: $5 copay Preferred brand: $15 copay Non-preferred: $50 copay Specialty: No coverage Preventive care (including vision exam) 0% (no deductible) Well child care (ages 0 to 6, including vision exam) 0% (no deductible) 0% (no deductible) Prenatal care 0% (no deductible) 0% (no deductible) Maternity (labor, delivery and post-delivery care) $200 copay per admission (facility) 10% (no deductible, professional services) Emergency care 0% (no deductible) $150 copay 0% (no deductible) $150 copay Ambulance 10% (no deductible) 10% (no deductible) Ambulatory surgical center 10% (no deductible) Hospital (outpatient) lab and diagnostic imaging/x-ray services Hospital visit (inpatient) Chiropractic, physical, occupational and speech therapy 10% (no deductible) 10% (no deductible) 10% (no deductible) 10% (no deductible) $200 copay per admission 10% (no deductible) Eyewear for children ages 18 and under lenses and one pair of frames or contact lenses 10% (no deductible) 20
Your out-of-pocket costs depend on the network status of your provider. To check status, use the Find a doctor web tool on bluecrossmn.com. Lowest out-of-pocket costs: in-network providers Higher out-of-pocket costs: out-of-network participating providers Highest out-of-pocket costs: out-of-network nonparticipating providers If you receive services from a nonparticipating provider, you will be responsible for any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-of-pocket maximum. This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross allowed amount, which is typically lower than the amount billed by the provider. This is only a summary. Your contract will provide a detailed description of what is and is not covered. Services not covered include custodial care or rest cures, bariatric surgery, infertility, adult eyewear, adult dental services, services that are experimental, not medically necessary or received while on military duty and certain services for the treatment of autism. Online Care Anywhere is not available in every state. Check OnlineCareAnywhereMN.com to ensure you are located in a state that is eligible to participate. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. This information is also available in other ways to people with disabilities. To reach customer service, call (651) 662-5040 (voice) or 1-800-711-9875 (toll-free). For (TTY) call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carry over), or 1-877-627-3848 (speech-to-speech). Hours: 7 a.m. to 8 p.m., Central Time, Monday through Friday. Attention. If you want free help translating this information, call the above number. Atencion. Si desea recibir asistencia gratuita para traduca esta informacion, llame al numero que aparece mas arriba. Blue Cross may change premium rates: on an annual renewal date, when you add or delete a dependent, or if you move to a different Blue Cross plan. Factors that may affect changes in premium rates include the age of covered members, where you reside and whether a member uses tobacco. To see benefit and premium information about all Blue Cross actively marketed individual health plans available to you, please go to healthcare.gov. YD004, YDU56 AASS F10217R02 (8/14) 21
2015 BlueAccess Plan Rates Area 1 Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. 0-20 21 22 23 24 25 26 27 28 29 30 31 BlueAccess Gold No Deductible Plan 241 (AASQ) 275.67 309.74 309.74 309.74 309.74 310.98 317.17 324.60 336.68 346.60 351.55 358.99 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 186.66 209.73 209.73 209.73 209.73 210.56 214.76 219.79 227.97 234.68 238.04 243.07 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 175.72 197.44 197.44 197.44 197.44 198.23 202.18 206.92 214.62 220.94 224.10 228.84 BlueAccess HSA Gold $1800 Plan 240 (AASN) 245.68 276.05 276.05 276.05 276.05 277.15 282.67 289.30 300.06 308.90 313.31 319.94 BlueAccess HSA Silver $2000 Plan 238 (AATS) 214.43 240.93 240.93 240.93 240.93 241.90 246.72 252.50 261.89 269.60 273.46 279.24 BlueAccess HSA Silver $3000 Plan 239 (AATP) 230.10 258.54 258.54 258.54 258.54 259.57 264.74 270.95 281.03 289.30 293.44 299.64 BlueAccess Platinum No Deductible Plan 242 (AASS) 309.58 347.85 347.85 347.85 347.85 349.24 356.19 364.54 378.11 389.24 394.81 403.15 BlueAccess Silver $1500 Plan 237 (AATW) 230.09 258.53 258.53 258.53 258.53 259.57 264.74 270.94 281.03 289.30 293.43 299.64 32 33 34 35 36 37 38 39 40 41 42 43 BlueAccess Gold No Deductible Plan 241 (AASQ) 366.42 371.07 376.02 378.50 380.98 383.46 385.93 390.89 395.84 403.28 410.40 420.31 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 248.11 251.25 254.61 256.28 257.96 259.64 261.32 264.67 268.03 273.06 277.89 284.60 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 233.57 236.54 239.69 241.27 242.85 244.43 246.01 249.17 252.33 257.07 261.61 267.93 BlueAccess HSA Gold $1800 Plan 240 (AASN) 326.56 330.70 335.12 337.33 339.54 341.74 343.95 348.37 352.79 359.41 365.76 374.59 BlueAccess HSA Silver $2000 Plan 238 (AATS) 285.02 288.64 292.49 294.42 296.35 298.27 300.20 304.06 307.91 313.69 319.24 326.95 BlueAccess HSA Silver $3000 Plan 239 (AATP) 305.85 309.73 313.86 315.93 318.00 320.07 322.14 326.27 330.41 336.61 342.56 350.83 BlueAccess Platinum No Deductible Plan 242 (AASS) 411.50 416.72 422.29 425.07 427.85 430.63 433.42 438.98 444.55 452.90 460.90 472.03 BlueAccess Silver $1500 Plan 237 (AATW) 305.84 309.72 313.86 315.93 318.00 320.06 322.13 326.27 330.41 336.61 342.56 350.83 Rates effective January 1, 2015 Rates are subject to benefit changes mandated by law and annual adjustments Note: Your rate may change when you move into a different rate area or change plans. Your rate will also change on an annual renewal date based on your age and benefit plan selected.
44 45 46 47 48 49 50 51 52 53 54 55 BlueAccess Gold No Deductible Plan 241 (AASQ) 432.70 447.26 464.61 484.12 506.42 528.41 553.19 577.66 604.61 631.86 661.29 690.71 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 292.99 302.84 314.59 327.80 342.90 357.79 374.57 391.14 409.38 427.84 447.76 467.69 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 275.83 285.11 296.16 308.60 322.82 336.84 352.63 368.23 385.41 402.78 421.54 440.30 BlueAccess HSA Gold $1800 Plan 240 (AASN) 385.64 398.61 414.07 431.46 451.34 470.93 493.02 514.83 538.84 563.13 589.36 615.58 BlueAccess HSA Silver $2000 Plan 238 (AATS) 336.58 347.91 361.40 376.58 393.93 411.03 430.31 449.34 470.30 491.50 514.39 537.28 BlueAccess HSA Silver $3000 Plan 239 (AATP) 361.18 373.33 387.80 404.09 422.71 441.06 461.75 482.17 504.66 527.41 551.98 576.54 BlueAccess Platinum No Deductible Plan 242 (AASS) 485.94 502.29 521.77 543.68 568.73 593.43 621.25 648.73 679.00 709.61 742.65 775.70 BlueAccess Silver $1500 Plan 237 (AATW) 361.17 373.32 387.80 404.09 422.70 441.06 461.74 482.16 504.66 527.41 551.97 576.53 56 57 58 59 60 61 62 63 64+ BlueAccess Gold No Deductible Plan 241 (AASQ) 722.62 754.83 789.21 806.25 840.63 870.36 889.88 914.35 929.22 BlueAccess HSA Bronze $4500 Plan 235 (AASX) 489.29 511.10 534.38 545.92 569.19 589.33 602.54 619.11 629.19 BlueAccess HSA Bronze $5200 Plan 236 (AAT3) 460.63 481.17 503.08 513.94 535.86 554.81 567.25 582.85 592.32 BlueAccess HSA Gold $1800 Plan 240 (AASN) 644.02 672.72 703.37 718.55 749.19 775.69 793.08 814.89 828.15 BlueAccess HSA Silver $2000 Plan 238 (AATS) 562.10 587.15 613.90 627.15 653.89 677.02 692.20 711.23 722.79 BlueAccess HSA Silver $3000 Plan 239 (AATP) 603.17 630.05 658.75 672.97 701.67 726.49 742.78 763.20 775.62 BlueAccess Platinum No Deductible Plan 242 (AASS) 811.53 847.70 886.31 905.44 944.06 977.45 999.36 1026.84 1043.55 BlueAccess Silver $1500 Plan 237 (AATW) 603.16 630.04 658.74 672.96 701.66 726.48 742.77 763.19 775.59 Rates effective January 1, 2015 Rates are subject to benefit changes mandated by law and annual adjustments Note: Your rate may change when you move into a different rate area or change plans. Your rate will also change on an annual renewal date based on your age and benefit plan selected.