Medical Plan Highlights
Deductibles
| Deductible and Out-of-Pocket | Basic Plan | Basic Plus |
|---|---|---|
| Lifetime maximum | Unlimited | Unlimited |
| Plan year deductible (Plan Year July 1 - June 30) | $400 per person; $1,200 family | $100 per person; $200 per family |
| Plan year medical out-of-pocket maximum | $2,000 per person; $4,000 family | $1,000 per person; $2,000 family |
| Plan year prescription out-of-pocket maximum | $750 per person; $1,000 family | $300 per person; $500 per family (for all covered prescriptions) |
Preventative Care
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Routine physical, eye examinations and immunizations | 100% coverage | 100% coverage after deductible; $500 annual maximum | 100% coverage | 100% coverage after deductible; $500 annual maximum |
| Prenatal, postnatal care and well-child care | 100% coverage | 100% coverage after deductible; $500 annual maximum | 100% coverage | 100% coverage after deductible; $500 annual maximum |
Office Visits
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Illness or injury | 80% coverage after deductible | 80% coverage after deductible | $25 copayment for the office visit, deductible does not apply; 90% coverage for all other services after deductible | 90% coverage after deductible |
| Mental/Chemical health care | 80% coverage after deductible | 80% coverage after deductible | $25 copayment for the office visit, deductible does not apply; 90% coverage for all other services after deductible | 90% coverage after deductible |
| Physical, occupational and speech therapy | 80% coverage after deductible | 80% coverage after deductible | $25 copayment for the office visit, deductible does not apply; 90% coverage for all other services after deductible | 90% coverage after deductible |
| Chiropractic care (for neuromusculoskeletal conditions only) | 80% coverage after deductible | 80% coverage after deductible | $25 copayment for the office visit, deductible does not apply; 90% coverage for all other services after deductible | 90% coverage after deductible |
| Allergy injections | 80% coverage after deductible | 80% coverage after deductible | $25 copayment for the office visit, deductible does not apply; 90% coverage for all other services after deductible | 90% coverage after deductible |
Convenience Care
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-network |
|---|---|---|---|---|
| Convenience clinics (retail clinics) and Doctor on Demand | 100% after Retail Health Clinic office visit $10 copayment | 80% coverage after deductible | $15 copayment for the office visit, deductible does not apply; 90% coverage for all other services after deductible | 90% coverage after deductible |
Emergency Care
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Urgently needed care at an urgent care clinic or medical center | 80% coverage after deductible | 80% coverage after deductible | $25 copayment for the office visit, deductible does not apply; 90% coverage for all other services after deductible | 90% coverage after deductible |
| Emergency care at a hospital ER | 80% coverage after deductible | 80% coverage after deductible | 90% coverage after deductible | 90% coverage after deductible |
| Ambulance | 80% coverage after deductible | 80% coverage after deductible | 90% coverage after deductible | 90% coverage after deductible |
Inpatient Hospital Care
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Illness or injury | 80% coverage after deductible | 80% coverage after deductible | 90% coverage after deductible | 90% coverage after deductible |
| Mental/Chemical health care | 80% coverage after deductible | 80% coverage after deductible | 90% coverage after deductible | 90% coverage after deductible |
Outpatient Care
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Scheduled outpatient procedures | 80% coverage after deductible | 80% coverage after deductible | 100% coverage after deductible | 90% coverage after deductible |
| Outpatient Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT) scan | 80% coverage after deductible | 80% coverage after deductible | 90% coverage after deductible | 90% coverage after deductible |
Durable Medical Equipment
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Durable medical equipment and prosthetic devices | 80% coverage after deductible | 80% coverage after deductible | 90% coverage after deductible | 90% coverage after deductible |
Prescription Drugs
Retail Pharmacy Copayment for a 31-day supply, including specialty drugs
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Generic Preferred | $15 copayment (formulary contraceptives are covered at 100%) | 80% coverage after deductible | $10 copayment (formulary contraceptives are covered at 100%) | 90% coverage after deductible |
| Brand Preferred | $30 copayment (formulary contraceptives are covered at 100%) | 80% coverage after the deductible | $25 copayment (formulary contraceptives are covered at 100%) | 90% coverage after deductible |
| Non-Preferred | $45 copayment | 80% coverage after the deductible | $40 copayment |
Mail Order Pharmacy & Retail Pharmacy Copayment for 90-day supply
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Generic Preferred | $30 copayment | $30 copayment | $20 copayment | $20 copayment |
| Brand Preferred | $60 copayment | $60 copayment | $50 copayment | $50 copayment |
| Non-Preferred | $90 copayment | $90 copayment | $80 copayment | $80 copayment |
Important Notes
Your out-of-pocket costs depend on the network status of your provider. To check status, call Blue Cross customer service or visit bluecrossmn.com/umnrfi.
Lowest out-of-pocket costs: in-network providers
Highest out-of-pocket costs: out-of-network nonparticipating providers (You are responsible for the difference between Blue Cross' allowed amount and the amount billed by nonparticipating providers. This is in addition to any applicable deductible, copay or coins. Benefit payments are calculated on Blue Cross' amount, which is typically lower than the amount billed by the provider.)
This is only a summary. Read your benefit booklet for more information about what is and isn't covered. Services that aren't covered include those that are cosmetic, investigative, not medically necessary or covered by workers' compensation or no-fault insurance.
For more information, visit the Blue Cross website or call Blue Cross customer service at the number on the back of your member ID card.