hios 0984460 hios marketing name* hios product id* hpid...
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2015 Plans & Benefits Template v4.0 Blue Cross Blue ShieldHIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name* HIOS Product ID* HPID Network ID*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ) 49316MN101 MNN00149316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA) 49316MN101 MNN00149316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX) 49316MN101 MNN00149316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU) 49316MN101 MNN00149316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ) 49316MN101 MNN00149316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF) 49316MN101 MNN00149316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG) 49316MN101 MNN00149316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9) 49316MN101 MNN00149316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8) 49316MN100 MNN00349316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9) 49316MN100 MNN00349316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC) 49316MN100 MNN00349316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH) 49316MN100 MNN00349316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB) 49316MN100 MNN00349316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3) 49316MN100 MNN00349316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6) 49316MN100 MNN00349316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7) 49316MN133 MNN003
Minnesota Department of Commerce October 1, 2014 Page 1 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Service Area ID* Formulary ID*MNS001 MNF001MNS001 MNF001MNS001 MNF004MNS001 MNF002MNS001 MNF001MNS001 MNF001MNS001 MNF014MNS001 MNF003MNS003 MNF008MNS003 MNF007MNS003 MNF004MNS003 MNF001MNS003 MNF006MNS003 MNF006MNS003 MNF006MNS003 MNF001
Minnesota Department of Commerce October 1, 2014 Page 2 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Plan AttributesNew/Existing Plan?* Plan Type*New PPONew PPONew PPONew PPOExisting PPONew PPONew PPONew PPONew PPONew PPONew PPONew PPONew PPONew PPONew PPOExisting PPO
Minnesota Department of Commerce October 1, 2014 Page 3 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Level of Coverage* Unique Plan Design?*Bronze YesBronze YesSilver YesSilver YesSilver NoGold YesGold YesPlatinum YesBronze NoBronze YesSilver YesSilver NoSilver YesGold YesPlatinum YesCatastrophic No
Minnesota Department of Commerce October 1, 2014 Page 4 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
QHP/Non‐QHP*On the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the ExchangeOn the Exchange
Minnesota Department of Commerce October 1, 2014 Page 5 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Notice Required for Pregnancy*NoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo
Minnesota Department of Commerce October 1, 2014 Page 6 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Is a Referral Required for Specialist?*NoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo
Minnesota Department of Commerce October 1, 2014 Page 7 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Specialist(s) Requiring a Referral
Minnesota Department of Commerce October 1, 2014 Page 8 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Plan Level Exclusions
Minnesota Department of Commerce October 1, 2014 Page 9 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Limited Cost Sharing Plan Variation ‐ Est Advanced Payment$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Minnesota Department of Commerce October 1, 2014 Page 10 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
HSA Eligible*YesYesNoYesYesYesNoNoNoNoNoYesNoNoNoNo
Minnesota Department of Commerce October 1, 2014 Page 11 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
HSA/HRA Employer Contribution
Minnesota Department of Commerce October 1, 2014 Page 12 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
HSA/HRA Employer Contribution Amount
Minnesota Department of Commerce October 1, 2014 Page 13 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Child‐Only Offering*Allows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐OnlyAllows Adult and Child‐Only
Minnesota Department of Commerce October 1, 2014 Page 14 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Child Only Plan ID
Minnesota Department of Commerce October 1, 2014 Page 15 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Tobacco Wellness Program Offered*NoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo
Minnesota Department of Commerce October 1, 2014 Page 16 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Disease Management Programs OfferedAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, DiabetesAsthma, Heart Disease, Diabetes
Minnesota Department of Commerce October 1, 2014 Page 17 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Stand Alone Dental OnlyEHB Apportionment for Pediatric Dental
Minnesota Department of Commerce October 1, 2014 Page 18 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Guaranteed vs. Estimated Rate
Minnesota Department of Commerce October 1, 2014 Page 19 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
AV Calculator Additional Benefit DesignMaximum Coinsurance for Specialty Drugs
$200
$200$100
$200
Minnesota Department of Commerce October 1, 2014 Page 20 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Maximum Number of Days for Charging an Inpatient Copay?
Minnesota Department of Commerce October 1, 2014 Page 21 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Begin Primary Care Cost‐Sharing After a Set Number of Visit
3
3333
Minnesota Department of Commerce October 1, 2014 Page 22 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Begin Primary Care Deductible/ Coinsurance After a Set Num
Minnesota Department of Commerce October 1, 2014 Page 23 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Plan DatesPlan Effective Date* Plan Expiration Date1/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/20151/1/2015 12/31/2015
Minnesota Department of Commerce October 1, 2014 Page 24 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Geographic CoverageOut of Country Coverage*YesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
Minnesota Department of Commerce October 1, 2014 Page 25 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Out of Country Coverage DescriptionDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsurance
Minnesota Department of Commerce October 1, 2014 Page 26 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Out of Service Area Coverage*YesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
Minnesota Department of Commerce October 1, 2014 Page 27 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Out of Service Area Coverage DescriptionDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsuranceDeductible and coinsurance
Minnesota Department of Commerce October 1, 2014 Page 28 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
National Network*YesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
Minnesota Department of Commerce October 1, 2014 Page 29 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
URLsURL for Summary of Benefits & Coverage
Minnesota Department of Commerce October 1, 2014 Page 30 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
URL for Enrollment Payment
Minnesota Department of Commerce October 1, 2014 Page 31 of 32
2015 Plans & Benefits Template v4.0HIOS Issuer ID* 49316Issuer State* MNMarket Coverage* IndividualDental Only Plan* NoTIN* 41‐0984460Plan Identifiers
HIOS Plan ID*(Standard Component) Plan Marketing Name*49316MN1010001 BlueAccess HSA Bronze $4500 Plan 435 (AATZ)49316MN1010002 BlueAccess HSA Bronze $5200 Plan 436 (AAUA)49316MN1010003 BlueAccess Silver $1500 Plan 437 (AATX)49316MN1010004 BlueAccess HSA Silver $2000 Plan 438 (AATU)49316MN1010005 BlueAccess HSA Silver $3000 Plan 439 (AASZ)49316MN1010006 BlueAccess HSA Gold $1800 Plan 440 (AAUF)49316MN1010007 BlueAccess Gold No Deductible Plan 441 (AAUG)49316MN1010008 BlueAccess Platinum No Deductible Plan 442 (AAT9)49316MN1000001 BlueBasic Bronze $3000 Plan 444 (AAU8)49316MN1000002 BlueBasic Bronze $6200 Plan 443 (AAU9)49316MN1000003 BlueBasic Silver $2100 Plan 445 (AAUC)49316MN1000004 BlueBasic HSA Silver $3500 Plan 447 (AATH)49316MN1000005 BlueBaisc Silver $4500 Plan 446 (AAUB)49316MN1000006 BlueBasic Gold $2000 Plan 448 (AAU3)49316MN1000007 BlueBasic Platinum $1000 Plan 449 (AAU6)49316MN1330001 BlueSave Catastrophic $6200 Plan 456 (AAU7)
Plan Brochure
Minnesota Department of Commerce October 1, 2014 Page 32 of 32