Blue Plus Metro MN Gold Prescription Copay $1100 Plan 254

Health Insurance Plan Details (2024 Plan)

Monthly Premium

PPO
$ubsidy
Gold
Deductible
$1,100 /yr
Max Out-of-Pocket
$7,500 /yr

Details

Deductible (per individual) $1,100 /yr
Deductible (per family) $3,300 /yr
Max Out-of-Pocket (per individual) $7,500 /yr
Max Out-of-Pocket (per family) $15,000 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type PPO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit 20.00% Coinsurance after deductible
Specialist Visit 20.00% Coinsurance after deductible
Emergency Room 20.00% Coinsurance after deductible
Inpatient Facility 20.00% Coinsurance after deductible
Inpatient Physician 20.00% Coinsurance after deductible
Drug Costs
Generic Drugs $20 Copay
Preferred Brand Drugs $60 Copay
Non-preferred Brand Drugs $180 Copay
Specialty Drugs $540 Copay

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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