Healthy Savings Plan

Plan Details

Network

Blue Cross Blue Shield (BCBS)

Administrator

Blue Cross Blue Shield of MN

HSA Eligible

Yes

FSA Eligible

Limited Purpose Flexible Spending Account

Medical Services

	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible - Individual	$2,500	$2,500
Annual Deductible - Family	$5,000	$5,000
Coinsurance (Employee Pays)	20%*	35%*
Annual Out-of-Pocket Maximum* - Individual Medical	$5,000	$7,600
Annual Out-of-Pocket Maximum* - Family Medical	$10,000	$15,200
Annual Out-of-Pocket Maximum* - Individual Drug	Included in Medical OOP	Included in Medical OOP
Annual Out-of-Pocket Maximum* - Family Drug	Included in Medical OOP	Included in Medical OOP

Annual Deductible - Individual

IN-NETWORK$2,500

OUT-OF-NETWORK$2,500

Annual Deductible - Family

IN-NETWORK$5,000

OUT-OF-NETWORK$5,000

Coinsurance (Employee Pays)

IN-NETWORK20%*

OUT-OF-NETWORK35%*

Annual Out-of-Pocket Maximum* - Individual Medical

IN-NETWORK$5,000

OUT-OF-NETWORK$7,600

Annual Out-of-Pocket Maximum* - Family Medical

IN-NETWORK$10,000

OUT-OF-NETWORK$15,200

Annual Out-of-Pocket Maximum* - Individual Drug

IN-NETWORKIncluded in Medical OOP

OUT-OF-NETWORKIncluded in Medical OOP

Annual Out-of-Pocket Maximum* - Family Drug

IN-NETWORKIncluded in Medical OOP

OUT-OF-NETWORKIncluded in Medical OOP

*After deductible All plans pay 100% once OOP is reached

Medical Services

	IN-NETWORK	OUT-OF-NETWORK
Copays/Coinsurance - Preventive Care	$0	35%
Copays/Coinsurance - Primary Care	20%*	35%*
Copays/Coinsurance - Specialist Services	20%*	35%*
Copays/Coinsurance - Diagnostic Care	20%*	35%*
Copays/Coinsurance - Mental Health - Inpatient	20%*	35%*
Copays/Coinsurance - Mental Health - Outpatient	20%*	35%*
Copays/Coinsurance - Urgent Care	20%*	35%*
Copays/Coinsurance - Emergency Room	$300 + 20%*	$300 + 20%*

Copays/Coinsurance - Preventive Care

IN-NETWORK$0

OUT-OF-NETWORK35%

Copays/Coinsurance - Primary Care

IN-NETWORK20%*

OUT-OF-NETWORK35%*

Copays/Coinsurance - Specialist Services

IN-NETWORK20%*

OUT-OF-NETWORK35%*

Copays/Coinsurance - Diagnostic Care

IN-NETWORK20%*

OUT-OF-NETWORK35%*

Copays/Coinsurance - Mental Health - Inpatient

IN-NETWORK20%*

OUT-OF-NETWORK35%*

Copays/Coinsurance - Mental Health - Outpatient

IN-NETWORK20%*

OUT-OF-NETWORK35%*

Copays/Coinsurance - Urgent Care

IN-NETWORK20%*

OUT-OF-NETWORK35%*

Copays/Coinsurance - Emergency Room

IN-NETWORK$300 + 20%*

OUT-OF-NETWORK$300 + 20%*

*After deductible All plans pay 100% once OOP is reached

Prescription Drugs - Out-of-Pocket Maximum

	IN-NETWORK	OUT-OF-NETWORK
Out-of-Pocket Maximum	Included in Medical Out-of-Pocket Maximum	Included in Medical Out-of-Pocket Maximum

Out-of-Pocket Maximum

IN-NETWORKIncluded in Medical Out-of-Pocket Maximum

OUT-OF-NETWORKIncluded in Medical Out-of-Pocket Maximum

*After deductible

RETAIL RX (30-DAY SUPPLY)

	IN-NETWORK	OUT-OF-NETWORK
Generic	20%*	20%*
Preferred	20%*	20%*
Non-Preferred	20%*	20%*
Specialty Drugs	20%*	Not covered

Generic

IN-NETWORK20%*

OUT-OF-NETWORK20%*

Preferred

IN-NETWORK20%*

OUT-OF-NETWORK20%*

Non-Preferred

IN-NETWORK20%*

OUT-OF-NETWORK20%*

Specialty Drugs

IN-NETWORK20%*

OUT-OF-NETWORKNot covered

*After deductible

MAIL ORDER RX (90-DAY SUPPLY)

	IN-NETWORK	OUT-OF-NETWORK
Generic	20%*	20%*
Preferred	20%*	20%*
Non-Preferred	20%*	20%*
Specialty Drugs	20%*	Not covered

Generic

IN-NETWORK20%*

OUT-OF-NETWORK20%*

Preferred

IN-NETWORK20%*

OUT-OF-NETWORK20%*

Non-Preferred

IN-NETWORK20%*

OUT-OF-NETWORK20%*

Specialty Drugs

IN-NETWORK20%*

OUT-OF-NETWORKNot covered

*After deductible

Plan Notes

The Healthy Savings Plan Option is a high deductible health plan.
An HSA is available with this plan, and you can also contribute to a Limited Purpose FSA.
Visit bluecrossmn.com/hormelfoods or call Customer Care at 866-537-7721 for a list of Blue Cross Blue Shield network providers.