Name of Manual - Blue Cross and Blue Shield of Minnesota

Blue Plus Coverage Options
Health Care Options
Comprehensive Plan This Blue Plus plan places a major emphasis on staying well,
maintaining fitness, and preventing potential health problems by
providing full coverage for basic care, such as annual physical
examinations, PAP tests, immunizations, and vaccinations, when
members use their predesignated clinic. Basic to this
comprehensive plan is coverage for lab work, X-rays, hospital care
and specialists’ consultations when provided or authorized by the
predesignated clinic. The plan also covers emergency treatment
anywhere in the world.
Preferred Gold SM Preferred Gold, a ‘‘triple option’’ plan, offers its members three
levels of benefits, depending on which provider network they elect
to use. Preferred Gold members select a primary care clinic and
receive the highest level of coverage for medical care provided or
authorized by that clinic. Access to ob/gyn care and other open
access benefits is available without a referral. Office visit copays
may apply. Specialist care, when referred by the primary care
clinic, is also covered.
Preferred Gold also offers its members the opportunity to self refer
to any provider or hospital and still receive coverage at a reduced
level. Under this second benefit level, Preferred Gold members
may use providers from Blue Cross’ extended network and receive
80 percent coverage after an annual deductible for most services.
Under the third level, out-of-network providers may be used, but
benefits are reduced or unavailable.
Triple Gold Triple Gold is a ‘‘triple option’’ plan for self-insured groups. It is
structured very much like Preferred Gold, but benefits may vary.
Medicare Select
Product
Medicare is primary for all services. For the highest level of
benefits, all care must be provided or referred by the member’s
primary care clinic. There are no benefits under the Medicare
Select contract for services outside the network, although coverage
through Medicare for eligible services is still available to the
member. Medical emergencies, however, are covered whether a
member is at home or traveling. The applicable Medicare
deductible and coinsurance amounts are the member’s
responsibility. Enrollment in Medicare Select is closed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-19