Traditional Plan

A lower deductible health plan with medical and prescription drug spending separated.

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Plan Details

Network

Blue Cross Blue Shield of MN

Administrator

Blue Cross Blue Shield of Minnesota

HSA Eligible

FSA Eligible

Healthcare 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	$44.00	$50.00	$57.00
Employee + Children	$70.00	$79.00	$91.00
Family	$120.00	$139.00	$153.00

Coverage LevelSingle

Tier 1 (under $75k)$44.00

Tier 2 ($75k-$149,999)$50.00

Tier 3 ($150k+)$57.00

Coverage LevelEmployee + Children

Tier 1 (under $75k)$70.00

Tier 2 ($75k-$149,999)$79.00

Tier 3 ($150k+)$91.00

Coverage LevelFamily

Tier 1 (under $75k)$120.00

Tier 2 ($75k-$149,999)$139.00

Tier 3 ($150k+)$153.00

COBRA Monthly Rates

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

Coverage Level	Monthly Rate
Single	$660.45
Employee + Children	$1,254.85
Family	$2,113.44

Coverage LevelSingle

Monthly Rate$660.45

Coverage LevelEmployee + Children

Monthly Rate$1,254.85

Coverage LevelFamily

Monthly Rate$2,113.44

Deductibles, Coinsurance & Out-of-Pocket Maximums

	In-Network	Out-of-Network
Deductible - Individual	$850	$850
Deductible - Family	$1,700	$1,700
Coinsurance (plan pays)	80%	65%
Out-of-Pocket Max - Individual	$4,000	$7,500
Out-of-Pocket Max - Family	$8,000	$15,000

Deductible - Individual

In-Network$850

Out-of-Network$850

Deductible - Family

In-Network$1,700

Out-of-Network$1,700

Coinsurance (plan pays)

In-Network80%

Out-of-Network65%

Out-of-Pocket Max - Individual

In-Network$4,000

Out-of-Network$7,500

Out-of-Pocket Max - Family

In-Network$8,000

Out-of-Network$15,000

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%	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%

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	10% (min. $5)	10% (min. $5)
Retail 30-day - Preferred	20% (min. $5)	20% (min. $5)
Retail 30-day - Non-Preferred	35% (min. $5)	35% (min. $5)
Retail 30-day - Specialty	Refer to applicable prescription drug cost-sharing	Not covered
Mail 90-day - Generic	10% (min. $5)	10%
Mail 90-day - Preferred	20% (min. $5)	20% after deductible
Mail 90-day - Non-Preferred	35% (min. $5)	35% after deductible
Mail 90-day - Specialty	Refer to applicable prescription drug cost-sharing	Not covered
Pharmacy Out-of-Pocket Max	$2,500	$5,000

TierRetail 30-day - Generic

In-Network10% (min. $5)

Out-of-Network10% (min. $5)

TierRetail 30-day - Preferred

In-Network20% (min. $5)

Out-of-Network20% (min. $5)

TierRetail 30-day - Non-Preferred

In-Network35% (min. $5)

Out-of-Network35% (min. $5)

TierRetail 30-day - Specialty

In-NetworkRefer to applicable prescription drug cost-sharing

Out-of-NetworkNot covered

TierMail 90-day - Generic

In-Network10% (min. $5)

Out-of-Network10%

TierMail 90-day - Preferred

In-Network20% (min. $5)

Out-of-Network20% after deductible

TierMail 90-day - Non-Preferred

In-Network35% (min. $5)

Out-of-Network35% after deductible

TierMail 90-day - Specialty

In-NetworkRefer to applicable prescription drug cost-sharing

Out-of-NetworkNot covered

TierPharmacy Out-of-Pocket Max

In-Network$2,500

Out-of-Network$5,000

Plan Notes

The Traditional Plan Option is a lower deductible health plan. Medical and prescription drug spending are separated under this plan.