Healthy Savings Plan

A high deductible health plan paired with a Health Savings Account (HSA).

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Plan Details

Network

Blue Cross Blue Shield of MN

Administrator

Blue Cross Blue Shield of Minnesota

HSA Eligible

Yes

FSA Eligible

Limited Purpose Flexible Spending Account

Weekly Premiums

Premiums are based on your annual salary tier.

Coverage Level	Tier 1 (under $75k)	Tier 2 ($75k-$149,999)	Tier 3 ($150k+)
Single	$24.00	$32.00	$38.00
Employee + Children	$33.00	$47.00	$58.00
Family	$53.00	$78.00	$96.00

Coverage LevelSingle

Tier 1 (under $75k)$24.00

Tier 2 ($75k-$149,999)$32.00

Tier 3 ($150k+)$38.00

Coverage LevelEmployee + Children

Tier 1 (under $75k)$33.00

Tier 2 ($75k-$149,999)$47.00

Tier 3 ($150k+)$58.00

Coverage LevelFamily

Tier 1 (under $75k)$53.00

Tier 2 ($75k-$149,999)$78.00

Tier 3 ($150k+)$96.00

COBRA Monthly Rates

COBRA monthly rate (Medical/Rx portion only, without 2% administrative fee)

Coverage Level	Monthly Rate
Single	$723.10
Employee + Children	$1,373.90
Family	$2,313.93

Coverage LevelSingle

Monthly Rate$723.10

Coverage LevelEmployee + Children

Monthly Rate$1,373.90

Coverage LevelFamily

Monthly Rate$2,313.93

Deductibles, Coinsurance & Out-of-Pocket Maximums

	In-Network	Out-of-Network
Deductible - Individual	$2,500	$2,500
Deductible - Family	$5,000	$5,000
Coinsurance (plan pays)	80%	65%
Out-of-Pocket Max - Individual	$5,000	$7,600
Out-of-Pocket Max - Family	$10,000	$9,000

Deductible - Individual

In-Network$2,500

Out-of-Network$2,500

Deductible - Family

In-Network$5,000

Out-of-Network$5,000

Coinsurance (plan pays)

In-Network80%

Out-of-Network65%

Out-of-Pocket Max - Individual

In-Network$5,000

Out-of-Network$7,600

Out-of-Pocket Max - Family

In-Network$10,000

Out-of-Network$9,000

All plans pay 100% once the out-of-pocket maximum is reached.

Covered Services

Service	In-Network	Out-of-Network
Preventive Care	$0	35%
Primary Care Visit	20% after deductible	35% after deductible
Specialist Visit	20% after deductible	35% after deductible
Diagnostic Care	20% after deductible	35% after deductible
Mental Health - Inpatient	20% after deductible	35% after deductible
Mental Health - Outpatient	20% after deductible	35% after deductible
Urgent Care	20% after deductible	35% after deductible
Emergency Room	$300 + 20% after deductible	$300 + 20% after deductible

ServicePreventive Care

In-Network$0

Out-of-Network35%

ServicePrimary Care Visit

In-Network20% after deductible

Out-of-Network35% after deductible

ServiceSpecialist Visit

In-Network20% after deductible

Out-of-Network35% after deductible

ServiceDiagnostic Care

In-Network20% after deductible

Out-of-Network35% after deductible

ServiceMental Health - Inpatient

In-Network20% after deductible

Out-of-Network35% after deductible

ServiceMental Health - Outpatient

In-Network20% after deductible

Out-of-Network35% after deductible

ServiceUrgent Care

In-Network20% after deductible

Out-of-Network35% after deductible

ServiceEmergency Room

In-Network$300 + 20% after deductible

Out-of-Network$300 + 20% after deductible

Prescription Drug Coverage

Tier	In-Network	Out-of-Network
Retail 30-day - Generic	20% after deductible	20% after deductible
Retail 30-day - Preferred	20% after deductible	20% after deductible
Retail 30-day - Non-Preferred	20% after deductible	20% after deductible
Retail 30-day - Specialty	20% after deductible	Not covered
Mail 90-day - Generic	20% after deductible	20% after deductible
Mail 90-day - Preferred	20% after deductible	20% after deductible
Mail 90-day - Non-Preferred	20% after deductible	20% after deductible
Mail 90-day - Specialty	20% after deductible	Not covered
Pharmacy Out-of-Pocket Max	Subject to medical deductible	Subject to medical deductible

TierRetail 30-day - Generic

In-Network20% after deductible

Out-of-Network20% after deductible

TierRetail 30-day - Preferred

In-Network20% after deductible

Out-of-Network20% after deductible

TierRetail 30-day - Non-Preferred

In-Network20% after deductible

Out-of-Network20% after deductible

TierRetail 30-day - Specialty

In-Network20% after deductible

Out-of-NetworkNot covered

TierMail 90-day - Generic

In-Network20% after deductible

Out-of-Network20% after deductible

TierMail 90-day - Preferred

In-Network20% after deductible

Out-of-Network20% after deductible

TierMail 90-day - Non-Preferred

In-Network20% after deductible

Out-of-Network20% after deductible

TierMail 90-day - Specialty

In-Network20% after deductible

Out-of-NetworkNot covered

TierPharmacy Out-of-Pocket Max

In-NetworkSubject to medical deductible

Out-of-NetworkSubject to medical deductible

Plan Notes

The Healthy Savings Plan Option is a high deductible health plan. You will pay 100% of medical and prescription costs until your deductible has been met.