Blue Cross Blue Shield Simply Blue

Inpatient and outpatient hospital services
Simply Blue Monthly Cost	Plan 1	Plan 2	Plan 3
Age 90 days-18	$106.00	$92.50	$77.00	contact us
19-29	$120.50	$105.00	$87.50	call 1-877-800-7340
30-34	$133.50	$116.50	$97.00	(612)991-3546
35-39	$138.50	$121.50	$101.00	M-Sat 8-8
40-44	$155.50	$136.00	$113.50
45-49	$194.00	$170.00	$141.50
50-54	$257.50	$225.50	$187.50

Annual deductible	$5,000	$7,500	$10,000	Simply Blue Dental

Out-of-pocket maximum	Equal to the deductible


Choose a plan
Office visits In the doctor's office or urgent care facility (within the network) for an illness or injury including allergy testing, serum and injections, and lab and X-ray services	Plan pays 100% of first $1,000, then 100% after you meet your deductible* see brochure PDF	Plan pays 100% of first $750, then 100% after you meet your deductible* see brochure PDF	Plan pays 100% of first $500, then 100% after you meet your deductible*see brochure PDF	prefer paper application download
Preventive care (routine physicals, eye exams, cancer screening)	Plan pays annual preventive care visit up to $200, then pays as office visit
Prescription drugs 31-day supply maintenance prescriptions: 90-day supply available through 90dayRx program at participating retail pharmacies or by mail order	100% coverage for generic drugs $25 co pay for formulary brand-name drugs $50 co pay for non-formulary brand-name drugs	100% coverage for generic drugs $35 co pay for formulary brand-name drugs $70 co pay for non-formulary brand-name drugs	$15 co pay coverage for generic drugs $50 co pay for formulary brand-name drugs $80 co pay for non-formulary brand-name drugs
Emergency room care	100% after $250 co pay for first visit each year; additional visits covered 100% after deductible*
Discounts and wellness programs	Fitness discounts program, online wellness center, stop-smoking program, 24-hour nurse advice line
Inpatient and outpatient lab and X-ray services	100% after deductible*
Ambulance
Medical supplies
Chiropractic, occupational, physical and speech therapy
Home health care
Behavioral health/mental health care
Behavioral health/substance abuse (You can decline this coverage and receive a lower rate)
Prenatal care	100%
Maternity labor, delivery and post-delivery care	No coverage
Lifetime maximum benefit per person	$5 million
Print application
Choose a plan				no obligation to buy please.
Notes	*Plan payment is based on the allowed amount when you use a participating provider. You are responsible for charges greater than the allowed amount when you use a non-participating Blue Cross provider. Coverage for substance abuse is included in the contract. You may choose to delete substance abuse coverage. Your premium will be slightly reduced if you delete substance abuse coverage. Dependents may not be added to this plan, but they can apply for their own Simply Blue plan. This is only a summary Your contract will provide a detailed description of what is and is not covered. Services not covered include childbirth labor and delivery, private-duty nursing, custodial care or rest cures, eyewear, dental services, hearing aids, services that are experimental, not medically necessary or received while on military duty. Pre-existing condition you had during the six months before your enrollment date are not covered. This limit applies for 12 months. Prior continuous coverage without a gap in coverage greater than 63 days counts toward reducing the 12-month period.

This is only a summary