BCBS PPO PLAN
Medical Plan Summary
Annual Deductible - Individual
IN-NETWORK$850
OUT-OF-NETWORK$850
Annual Deductible - Family
IN-NETWORK$2,550
OUT-OF-NETWORK$2,550
Annual Deductible - 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
Copays/Coinsurance - Preventive Care
IN-NETWORK$0
OUT-OF-NETWORK$10
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$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.