Provider Network
Campus Health Services
Primary Members Only; no dependents
When services are provided at the student's campus health services, only students paying the Student Service Fee (SSF) are eligible for this benefit.
Blue Cross Participating Partners
Primary Member and Dependents
When you use a provider who participates with Blue Cross, they will file the claims on your behalf. They have agreed to accept the allowed amount as payment in full, less your copayments.
Find participating providers: 1-800-810-2583 or visit the Blue Cross website
Nonparticipating Providers
Primary Member and Dependents
When you use a provider who does not participate with Blue Cross, you need to file your claim with Blue Cross for benefit processing. You are responsible for amounts i excess of allowed amount.
Medical Plan Highlights
The following benefits apply to students and their dependents enrolled in the University-sponsored Student Health Benefit Plan. This Quick Reference Benefit Chart is intended as a guide. For plan details, refer to the Office of Student Health Benefit's website.
Deductibles
| Deductible and Out-of-Pocket | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Lifetime maximum | Unlimited | Unlimited | Unlimited |
| Plan year deductible | Not applicable | $250 per person | $250 per person |
| Plan year medical out-of-pocket maximum | $6,250 per person | $6,250 person | $6,250 per person |
Preventative Care
| Covered Services | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Routine physical, eye examinations, immunizations, prenatal, postnatal care | 100% coverage | 100% coverage | 80% coverage after deductible |
| Well-child care, developmental assessments, immunizations and vaccinations (not covered after age 6) | 100% coverage | 100% coverage | 80% coverage after deductible (up to age 6) |
Office Visits
| Covered Services | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Illness or injury | 100% coverage | 80% coverage after deductible | 80% coverage after deductible |
| Mental/Chemical health care | Not applicable | 80% coverage after deductible | 80% coverage after deductible |
| Physical, occupational and speech therapy | Only applicable for Twin Cities Campus, $5 copayment | 80% coverage after deductible | 80% coverage after deductible |
| Chiropractic care (for neuromusculoskeletal conditions only) | Not applicable | 80% coverage after deductible | 80% coverage after deductible |
Convenience Care
| Covered Services | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Convenience clinics (retail clinics) | 100% coverage after $10 copayment | 100% coverage after $10 copayment | 100% coverage after $10 copayment |
Emergency Care
| Covered Services | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Urgently needed care at an urgent care clinic or medical center | 100% coverage | 80% coverage after deductible | 80% coverage after deductible |
| Emergency care at a hospital ER | Not applicable | 80% coverage after deductible | 80% coverage after deductible |
| Ambulance | Not applicable | 80% coverage after deductible | 80% coverage after deductible |
Inpatient Hospital Care
| Covered Services | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Illness or injury | Not applicable | 80% coverage after deductible | 80% coverage after deductible (pre-admission notification required or coverage is reduced by 25%) |
| Mental/Chemical health care | Not applicable | 80% coverage after deductible | 80% coverage after deductible (pre-admission notification required or coverage is reduced by 25%) |
Outpatient Care
| Covered Services | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Scheduled outpatient procedures | Not applicable | 80% coverage after deductible | 80% coverage after deductible |
| Outpatient Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT) scan | Not applicable | 80% coverage after deductible | 80% coverage after deductible |
Durable Medical Equipment
| Covered Services | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Durable medical equipment and prosthetic devices | Only applicable for Twin Cities campus, 80% coverage, 100% coverage for casts and crutches | 80% coverage after deductible | 80% coverage after deductible |
Prescription Drugs
Retail Pharmacy Copayment for a 31-day supply, including specialty drugs
| Covered Services | Campus Health | In-Network | Out-of-Network |
|---|---|---|---|
| Generic Preferred | $15 copayment (formulary contraceptives are covered at 100%) | 80% coverage after deductible | |
| Brand Preferred | $30 copayment (formulary contraceptives are covered at 100%) | 80% coverage after the deductible | |
| Non-Preferred | $45 copayment | 80% coverage after the deductible |
Mail Order Pharmacy & Retail Pharmacy Copayment for 90-day supply
| Covered Services | Basic In-Network | Basic Out-of-Network | Basic Plus In-Network | Basic Plus Out-of-Network |
|---|---|---|---|---|
| Generic Preferred | $30 copayment | $30 copayment | $20 copayment | $20 copayment |
| Brand Preferred | $60 copayment | $60 copayment | $50 copayment | $50 copayment |
| Non-Preferred | $90 copayment | $90 copayment | $80 copayment | $80 copayment |
Important Notes
Your out-of-pocket costs depend on the network status of your provider. To check status, call Blue Cross customer service or visit bluecrossmn.com/umnrfi.
Lowest out-of-pocket costs: in-network providers
Highest out-of-pocket costs: out-of-network nonparticipating providers (You are responsible for the difference between Blue Cross' allowed amount and the amount billed by nonparticipating providers. This is in addition to any applicable deductible, copay or coins. Benefit payments are calculated on Blue Cross' amount, which is typically lower than the amount billed by the provider.)
This is only a summary. Read your benefit booklet for more information about what is and isn't covered. Services that aren't covered include those that are cosmetic, investigative, not medically necessary or covered by workers' compensation or no-fault insurance.
For more information, visit the Blue Cross website or call Blue Cross customer service at the number on the back of your member ID card.