Suitability Discussion And Worksheet - Minnesota (Page 2 of 3) in pdf

Prescription Drug Coverage

 My prescription drugs are covered.

Prescription drug coverage varies by health plan. Blue Plus plans have a list of covered drugs called a

formulary or covered drug list. Drugs not on the formulary are not covered. It’s important you check

the health plan’s formulary to see if your drugs are covered before you enroll in the plan. To find

drugs covered by Blue Plus Individual plans, go to > Shop Plans > Individual and

Family Plans > See the covered drug list. Please use Chart B on the last page to research whether your

prescriptions are covered.

 My Pharmacy participates in the plan’s focused pharmacy network.

Blue Plus individual and family plans have a focused pharmacy network called “RxNetwork E.” Blue

Plus plans only provide coverage for prescriptions filled at pharmacies that participate in the

RxNetwork E. If you get a drug from a pharmacy that isn’t in RxNetwork E network, you’ll pay the

full cost for your drug. Those costs will not count toward your in-network cost sharing limits. A full

list of pharmacies within the RxNetwork E can be viewed at > Shop Plans >

Individual and Family Plans > Search the pharmacy network. Please use Chart C on the last page to

research whether your pharmacy is in the network.

Monthly Plan Premium

 I can afford this plan now and in the future.

Consider your current and future income and your living expenses. Remember that most premium

rates will increase over time. You should also take into consideration deductibles, coinsurance and

copays required by the plan when calculation your expenses.

Applicant: I have reviewed the details of the Individual and Family Plan I am applying for. I

understand I am enrolling in a plan with a focused provider and pharmacy network.

Applicant Printed Name

Applicant Signature of Acknowledgement

Date

Producer: I certify that I have reviewed with my client the suitability requirements described in

Minnesota Statute 60K.46 subdivision 4 regarding suitability. I further certify, I have reasonable

grounds to believe that the determination made regarding the recommendation of an Individual and

Family Plan is suitable for my client. In the event my client has selected a product for which I have

determined does not meet the suitability requirements, I certify that the product was selected

without my recommendation.

Producer Signature

Date

Suitability Discussion And Worksheet - Minnesota Page 2