*Authorized
independent agent/agency for Blue Cross and Blue Shield of
Minnesota.
Apply or Quote Personal
Blue Online
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PLAN HIGHLIGHTS
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Personal Blue 80 with co
pay |
Personal Blue 80 |
Personal Blue 100 |
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Calendar year deductible
No member can contribute more than the
individual amount toward a family deductible (combines
medical and drug expenses) |
Individual
1,000
$3,000 |
Family
$3,000
$9,000 |
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Individual
$1,500 $2,500 $3,500
$4,500 |
Family
$4,500
$7,500 $10,500 $13,500 |
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Individual
$4,000
$7,500
$10,000 $15,000 |
Family
$12,000
$22,500
$30,000 $45,000 |
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Out-of-pocket Maximum OOP
After this amount is reached, your
plan pays 100% of covered expenses
Copays do not apply to the out-of-pocket maximum
(combines medical and drug expenses) |
$2,000
$6,000
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$4,000
$12,000
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Individual
$3,000 $4,500 $,5000
$7,000 |
Family
$6,000
$9,000 $10,000 $14,000 |
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Individual
$4,000
$7,500
$10,000 $15,000 |
Family
$12,000
$22,500
$30,000 $45,000 |
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Coinsurance Percentage that
you pay after deductible |
you pay 20% after deductible |
you pay 20% after deductible |
you pay 0% after deductible |
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Lifetime maximum per person
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Unlimited |
Unlimited |
Unlimited |
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Prescription Drugs (GenRx Formulary) |
Covered $5 Generics
you pay 20% after
deductible formulary brand name drugs |
Covered $5 Generics
you pay 20% after
deductible formulary brand name drugs |
Covered $5 Generics
you pay 0 after deductible
formulary brand name drugs |
Preventive care for physicals and eye exams,
cancer screenings
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Covered
you pay $0 no deductible |
Covered
you pay $0 no deductible |
Covered
you pay $0 no deductible
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Physician services Office or urgent care
visits for all illness or injury includes mental health,
substance abuse, eating disorders, autism
Retail health clinic
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Covered
$50 copay
per visit plus 20% after deductible for related
services such as lab, X-rays, in-office surgery, allergy
services
$10 copay per visit plus 20% after
deductible for related services as described above
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Covered
You pay
20% after deductible for related services such as
lab, X-rays, in-office surgery, allergy services
You pay 20% coinsurance (no
deductible) plus 20% after deductible for related
services as described above
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Covered
You pay 0 after
deductible
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Inpatient/outpatient lab and diagnostic
imaging/X-ray services |
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Emergency
room |
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Inpatient/outpatient hospital services
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Ambulance
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Medical
supplies |
Chiropractic care
Maximum of $500 per person per calendar year
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Occupational, physical, speech therapy
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Home health
care
Up to $25,000 per person per calendar year
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Covered
You pay 20% after deductible
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Covered
You pay 20% after deductible
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Covered
You pay 0 after deductible
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This is only an outline of benefits. The
contract and certificate include complete details of what is and
isn't covered. Services not covered include eyeglasses, hearing
aids, items primarily used for a non-medical purpose,
over-the-counter drugs/nutritional supplements, services that
are cosmetic, experimental, not medically necessary, or covered
by workers' compensation or no-fault auto insurance.
Pre-existing conditions may not be covered for a limited period
of time. A pre-existing condition is a condition we have
determined existed up to (6) months immediately proceeding the
enrollment date of your coverage. Conditions are considered to
be pre-existing if medical advice, diagnosis, care or treatment
was recommended or received within the specified time frame. The
limit is reduced by prior continuous coverage and doesn't apply
to pregnancy, newborns, adopted children or handicapped
dependents. We feature a large network of health care providers.
Each provider is an independent contractor and is not our agent.
Nonparticipating providers do not have contracts Blue Cross and
Blue Shield of Minnesota.
Deductibles and out-of-pocket maximums are based on the Consumer
Price Index and may change annually. |
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