Name of Manual - Blue Cross and Blue Shield of Minnesota

Health Care Options
Double Gold Double Gold is a self-insured fee-for-service plan administered by
Blue Cross. Members have the freedom to see participating doctors
of their choice, however, the provider network for chiropractic and
behavioral health care may be limited depending on the employer
group. Office visit copays may apply.
Freedom 1-2-3 Is a new low-cost plan designed especially for employer groups
with 2-50 members? There is no coverage for certain mandated
benefits like chiropractic, mental health care, infertility and
bariatric surgery. This plan has a low deductible, with no office
visit copays. It includes generous upfront benefits for:
• One preventive care visit and one eye exam each year
• Two doctor’s office or urgent care visits each year
• Three retail health clinic visits each year
The group has the option to choose one of two networks. The
statewide Accord network or, in the 11-county metro area, our new
Value network.
Simply Blue SM Simply Blue offers essential health care coverage. The plan is
single coverage only ages 19-64. This plan offers three deductible
options, two drug options, and office visit copays. Substance abuse
coverage is optional. This plan offers the statewide Accord
network.
Personal Blue SM Personal Blue is a comprehensive major medical Individual plan
with some upfront coverage for office and retail health clinic office
visits and generic drug copay. There are a variety of deductible
options for members to choose from. This plan has family
coverage. Substance abuse coverage is optional. This plan offers
the statewide Accord network.
GoBlue GoBlue is our lowest cost plan that takes care of major expenses.
There are four deductible options and offers an urgent care and
generic drug copay. This plan is single coverage only for ages 19
through 64. This plan offers the statewide Accord network.
InstaCare InstaCare is our short-term coverage plan that offers immediate
protection. This plan does not cover preexisting conditions. There
are three deductible options to choose from and three contract term
durations – 30 day, 60 day, or 90 day.
5-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)