Simply Blue – Benefits
Get the coverage you need – and none you don’t
Benefits you want at a
price you can afford.
This is your health plan,
because you can
customize it. You pick
the deductible you want
and the drug coverage
you want. You get
immediate help paying
for doctor office visits,
and prescription drugs,
and full protection from
big medical costs. Simply
Blue: a smart plan at a
low cost.
Health plans are as
unique and individual as
you are.
And the kind of plan you
want can change as you
move from one stage of
your life to the next. So
whether you need a plan
just for you, or for you
and your family, a plan
with drug coverage
options or a health
savings account, you’ll
find one that fits you at
Blue Cross.
price you can afford.
This is your health plan,
because you can
customize it. You pick
the deductible you want
and the drug coverage
you want. You get
immediate help paying
for doctor office visits,
and prescription drugs,
and full protection from
big medical costs. Simply
Blue: a smart plan at a
low cost.
Health plans are as
unique and individual as
you are.
And the kind of plan you
want can change as you
move from one stage of
your life to the next. So
whether you need a plan
just for you, or for you
and your family, a plan
with drug coverage
options or a health
savings account, you’ll
find one that fits you at
Blue Cross.
| In-network plan features |
| Calendar-year deductible options Amount you pay toward health care before your plan starts to pay (combines medical and drug expenses) Choose one option. |
(a) $3,000
(b) $6,000
(c) $9,000
(b) $6,000
(c) $9,000
| Out-of-pocket (OOP) maximum Once deductible is reached, plan pays 100% of covered expenses Copays do not apply to the out-of-pocket maximum (combines medical and drug expenses) |
(a) $3,000
(b) $6,000
(c) $9,000
(b) $6,000
(c) $9,000
| Coinsurance Percentage that you pay after deductible |
You pay 0% after deductible
| Lifetime maximum |
Unlimited
| In-network benefits |
| Prescription drugs (GenRx formulary) 31-day supply. 90-day supply available through 90dayRx program at participating retail pharmacies or by PrimeMail 1 |
Option 1: $5 copay generics; $50 copay formulary brand; $90 copay non-formulary brand
Option 2: $10 copay generics; you pay 100% for formulary brand; no coverage for
non-formulary brand
Option 2: $10 copay generics; you pay 100% for formulary brand; no coverage for
non-formulary brand
| Physician services Office visit or retail health clinic visit for illness or injury |
Covered
(a) $30, (b) $40 or (c) $50 (depending on deductible) copay for first three visits; subsequent
visits you pay 0% after deductible
(a) $30, (b) $40 or (c) $50 (depending on deductible) copay for first three visits; subsequent
visits you pay 0% after deductible
| Urgent care visit |
$100 copay for the first visit; subsequent visits you pay 0% after deductible
| Emergency room care |
$250 copay for the first visit; subsequent visits you pay 0% after deductible
| All other professional services in the office Immunizations, surgery, anesthesia, ear washing, wart removal, inpatient and outpatient hospital visits |
Covered
You pay 0% after deductible
You pay 0% after deductible
| Preventive care |
Covered
You pay 0% (no deductible)
You pay 0% (no deductible)
| Inpatient/outpatient lab and diagnostic imaging/X-ray services |
Covered
You pay 0% after deductible
You pay 0% after deductible
| Inpatient/outpatient hospital services |
| Ambulance |
| Medical supplies |
| Chiropractic care Maximum of 15 services per person per calendar year |
| Occupational, physical, speech therapy |
| Home health care Maximum of 180 visits per person per calendar year |
| Maternity labor, delivery, post-delivery care and maternity complications* |
Not covered
| *If you are looking for maternity coverage, we have other plans available. When you choose a network provider you will receive the highest benefit levels and the lowest out-of-pocket costs. If you receive services from a nonparticipating provider, you will be responsible for: any deductibles or coinsurance plus the DIFFERENCE between what Blue Cross would reimburse for the nonparticipating provider and the actual charges the nonparticipating provider bills. This difference does not apply to your out-ofpocket 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 maternity labor and delivery, custodial care or rest cures, bariatric surgery, infertility, intensive behavioral therapy programs for treatment of autism spectrum disorders, eyewear, dental services, services that are experimental, not medically necessary or received while on military duty. Preexisting conditions you had during the six months before your enrollment date are not covered except for children under age 19. 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. Consumer Price Index: Deductible, copays, and out-of-pocket maximums are subject to adjustments at our annual renewal. 1 PrimeMail is a mail-service pharmacy owned and operated by Prime Therapeutics LLC, an independent company providing pharmacy benefit management services |
| Simply Blue health plan also protects your bank account |
You work hard for your money. An unexpected injury could take it all away, unless you have a health plan.
Here are some common injuries and their average medical costs*:
Here are some common injuries and their average medical costs*:
| MRI |
| $ 2,000 |
| Tonsil removal |
| $ 5,820 |
| Removing an appendix |
| $ 13,405 |
| Repairing a ruptured Achilles tendon |
| $ 17,480 |
| Fixing a torn knee meniscus |
| $ 17,500 |
*Source: surgerycosts.net, 2010
When you buy a health plan, you’ll get protection from high medical expenses like those shown above.
You get a choice
Simply Blue is an affordable and easy-
to-use health plan. You get great
coverage and can choose the options
that fit you best. Select one of three
annual deductibles and the higher your
deductible, the lower your premium.
You can also choose a drug coverage
option to cover just generic drugs, or
both generic and brand-name drugs.
Quick, hassle-free claims processing
We’ll handle your claims efficiently,
quickly, accurately and without hassle.
After all, isn’t that what a health plan
is for?
Unmatched service
When you call customer service, Health
Guides will answer your questions,
solve any issues you might have and
refer you to additional resources that
can help you save money and improve
your health.
Health care coverage anywhere in the
world
More than 97 percent of Minnesota
doctors and hospitals are in our
network, where you always get the
best benefit for your dollar. You’re also
“in network” virtually anywhere you go
in the United States with BlueCard®
and internationally through BlueCard
Worldwide®. And you never need a
referral.
Simply Blue is an affordable and easy-
to-use health plan. You get great
coverage and can choose the options
that fit you best. Select one of three
annual deductibles and the higher your
deductible, the lower your premium.
You can also choose a drug coverage
option to cover just generic drugs, or
both generic and brand-name drugs.
Quick, hassle-free claims processing
We’ll handle your claims efficiently,
quickly, accurately and without hassle.
After all, isn’t that what a health plan
is for?
Unmatched service
When you call customer service, Health
Guides will answer your questions,
solve any issues you might have and
refer you to additional resources that
can help you save money and improve
your health.
Health care coverage anywhere in the
world
More than 97 percent of Minnesota
doctors and hospitals are in our
network, where you always get the
best benefit for your dollar. You’re also
“in network” virtually anywhere you go
in the United States with BlueCard®
and internationally through BlueCard
Worldwide®. And you never need a
referral.
Be fit. Be rewarded.
Simply Blue can make a healthy difference in your
life with a health club discount of up to $20 per
month toward your membership fee at thousands
of participating health clubs. You also get a
personal online wellness center that includes a
health assessment, coaching support and more.
Your personal account at the myBlueCross online
member center will help you manage your health
and your health care expenses.
Save on prescription drugs and disposable
medical supplies
With 90dayRx, only from Blue Cross and Blue
Shield of Minnesota, you can fill 90-day
prescriptions at participating retail pharmacies or
through mail order and pay less than you would
for three separate 30-day prescriptions.
If you use disposable medical supplies, you can
get free home delivery and up to 10 percent
discount from Edgepark Medical Supplies.
A name that Minnesotans know
For more than 75 years Blue Cross has earned
the trust of our members by offering solid,
reliable health plans and service second to none.
That’s longer than any other health plan in the
state. Today, we serve nearly three million
members. And you can count on us being here
when you need us.
Simply Blue can make a healthy difference in your
life with a health club discount of up to $20 per
month toward your membership fee at thousands
of participating health clubs. You also get a
personal online wellness center that includes a
health assessment, coaching support and more.
Your personal account at the myBlueCross online
member center will help you manage your health
and your health care expenses.
Save on prescription drugs and disposable
medical supplies
With 90dayRx, only from Blue Cross and Blue
Shield of Minnesota, you can fill 90-day
prescriptions at participating retail pharmacies or
through mail order and pay less than you would
for three separate 30-day prescriptions.
If you use disposable medical supplies, you can
get free home delivery and up to 10 percent
discount from Edgepark Medical Supplies.
A name that Minnesotans know
For more than 75 years Blue Cross has earned
the trust of our members by offering solid,
reliable health plans and service second to none.
That’s longer than any other health plan in the
state. Today, we serve nearly three million
members. And you can count on us being here
when you need us.