BCBS PPO Plan
A lower deductible health plan with medical and prescription drug spending separated.
Plan Details
Network
Blue Cross Blue Shield (BCBS)
Administrator
Blue Cross Blue Shield of MN
HSA Eligible
No
FSA Eligible
Yes
Deductibles, Coinsurance & Out-of-Pocket Maximums
Annual deductible - Individual
IN-NETWORK$850
OUT-OF-NETWORK$850
Annual deductible - Family
IN-NETWORK$2,550
OUT-OF-NETWORK$2,550
Coinsurance (Employee pays)
IN-NETWORK20%*
OUT-OF-NETWORK35%*
Annual out-of-pocket maximum* - Individual medical
IN-NETWORK$4,250
OUT-OF-NETWORK$7,500
Annual out-of-pocket maximum* - Family medical
IN-NETWORK$9,350
OUT-OF-NETWORK$15,850
Annual out-of-pocket maximum* - Individual drug
IN-NETWORK$2,750
OUT-OF-NETWORK$2,750
Annual out-of-pocket maximum* - Family drug
IN-NETWORK$5,500
OUT-OF-NETWORK$5,500
Preventive care
IN-NETWORK$0
OUT-OF-NETWORK$10
Primary care
IN-NETWORK20%*
OUT-OF-NETWORK35%*
Specialist services
IN-NETWORK20%*
OUT-OF-NETWORK35%*
Diagnostic care
IN-NETWORK20%*
OUT-OF-NETWORK35%*
Mental health - Inpatient
IN-NETWORK20%*
OUT-OF-NETWORK35%*
Mental health - Outpatient
IN-NETWORK20%
OUT-OF-NETWORK35%*
Urgent care
IN-NETWORK20%*
OUT-OF-NETWORK35%*
Emergency room
IN-NETWORK$100 + 20%*
OUT-OF-NETWORK$100 + 20%*
*After deductible Plan pays 100% once OOP is reached
Prescription Drug Coverage for Medical Plan
Individual out-of-pocket maximum
IN-NETWORK$2,750
OUT-OF-NETWORK$2,750
Family out-of-pocket maximum
IN-NETWORK$5,500
OUT-OF-NETWORK$5,500
Retail Rx (30-day supply) - Generic
IN-NETWORK10% (min. $5)
OUT-OF-NETWORK10% (min. $5)
Retail Rx (30-day supply) - Preferred
IN-NETWORK20% (min. $5)
OUT-OF-NETWORK20% (min. $5)
Retail Rx (30-day supply) - Non-preferred
IN-NETWORK35% (min. $5)
OUT-OF-NETWORK35% (min. $5)
Retail Rx (30-day supply) - Specialty drugs
IN-NETWORKRefer to applicable prescription drug cost-sharing
OUT-OF-NETWORKNot covered
Mail order Rx (90-day supply) - Generic
IN-NETWORK10% (min. $5)
OUT-OF-NETWORK10%
Mail order Rx (90-day supply) - Preferred
IN-NETWORK20% (min. $5)
OUT-OF-NETWORK20%*
Mail order Rx (90-day supply) - Non-preferred
IN-NETWORK35% (min. $5)
OUT-OF-NETWORK35%*
Mail order Rx (90-day supply) - Specialty drugs
IN-NETWORKRefer to applicable prescription drug cost-sharing
OUT-OF-NETWORKNot covered
*After deductible
Plan Notes
- Hormel Foods’ medical plans are self-insured, helping keep costs down by cutting out the insurance carrier’s profits.
- All covered services are subject to medical necessity as determined by the plan, and out-of-network services are subject to Reasonable and Customary (R&C) limitations.
- Visit bluecrossmn.com/hormelfoods or call Customer Care at 866-537-7721 for a list of Blue Cross Blue Shield network providers.