Traditional Plan

Plan Details

Network

Blue Cross Blue Shield (BCBS)

Administrator

Blue Cross Blue Shield of MN

HSA Eligible

FSA Eligible

Healthcare Flexible Spending Account

Medical Services

	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible - Individual	$850	$850
Annual Deductible - Family	$1,700	$1,700
Coinsurance (Employee Pays)	20%*	35%*
Annual Out-of-Pocket Maximum* - Individual Medical	$4,000	$7,500
Annual Out-of-Pocket Maximum* - Family Medical	$8,000	$15,000
Annual Out-of-Pocket Maximum* - Individual Drug	$2,500	$2,500
Annual Out-of-Pocket Maximum* - Family Drug	$5,000	$5,000

Annual Deductible - Individual

IN-NETWORK$850

OUT-OF-NETWORK$850

Annual Deductible - Family

IN-NETWORK$1,700

OUT-OF-NETWORK$1,700

Coinsurance (Employee Pays)

IN-NETWORK20%*

OUT-OF-NETWORK35%*

Annual Out-of-Pocket Maximum* - Individual Medical

IN-NETWORK$4,000

OUT-OF-NETWORK$7,500

Annual Out-of-Pocket Maximum* - Family Medical

IN-NETWORK$8,000

OUT-OF-NETWORK$15,000

Annual Out-of-Pocket Maximum* - Individual Drug

IN-NETWORK$2,500

OUT-OF-NETWORK$2,500

Annual Out-of-Pocket Maximum* - Family Drug

IN-NETWORK$5,000

OUT-OF-NETWORK$5,000

*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	$2,500	$5,000

Out-of-Pocket: Maximum

IN-NETWORK$2,500

OUT-OF-NETWORK$5,000

*After deductible

RETAIL RX (30-DAY SUPPLY)

	IN-NETWORK	OUT-OF-NETWORK
Generic	10% (min. $5)	10% (min. $5)
Preferred	20% (min. $5)	20% (min. $5)
Non-Preferred	35% (min. $5)	35% (min. $5)
Specialty Drugs	Refer to applicable prescription drug cost-sharing	Not covered

Generic

IN-NETWORK10% (min. $5)

OUT-OF-NETWORK10% (min. $5)

Preferred

IN-NETWORK20% (min. $5)

OUT-OF-NETWORK20% (min. $5)

Non-Preferred

IN-NETWORK35% (min. $5)

OUT-OF-NETWORK35% (min. $5)

Specialty Drugs

IN-NETWORKRefer to applicable prescription drug cost-sharing

OUT-OF-NETWORKNot covered

*After deductible

MAIL ORDER RX (90-DAY SUPPLY)

	IN-NETWORK	OUT-OF-NETWORK
Generic	10% (min. $5)	10%
Preferred	20% (min. $5)	20%*
Non-Preferred	35% (min. $5)	35%*
Specialty Drugs	Refer to applicable prescription drug cost-sharing	Not covered

Generic

IN-NETWORK10% (min. $5)

OUT-OF-NETWORK10%

Preferred

IN-NETWORK20% (min. $5)

OUT-OF-NETWORK20%*

Non-Preferred

IN-NETWORK35% (min. $5)

OUT-OF-NETWORK35%*

Specialty Drugs

IN-NETWORKRefer to applicable prescription drug cost-sharing

OUT-OF-NETWORKNot covered

*After deductible

Plan Notes

The Traditional Plan Option is a low deductible health plan.
Hormel Foods’ medical plans are self-insured, helping keep costs down by cutting out the insurance carrier’s profits.
Visit bluecrossmn.com/hormelfoods or call Customer Care at 866-537-7721 for a list of Blue Cross Blue Shield network providers.