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

Suitability Discussion And Worksheet - Minnesota Page 3

Suitability Worksheet

Chart A. Provider Network

To search for a provider go to > Shop Plans > Individual and Family Plans > Find a doctor in

the network. Please use the following chart to write in your doctors, clinics or hospitals to help you determine

whether they are in or out of the plan’s network.

 BlueConnect – Sanford Health Network

 Blue Plus – St. Luke’s

Western Minnesota

Northeastern Minnesota

 BluePrint – Allina Health Network

 Blue Plus – Mayo Clinic

Twin Cites Metro Area

Southeastern Minnesota

Doctor, Clinic or Hospital

In the plan network (Y/N)

Chart B. Prescription Drug Coverage

To find drugs that are covered by Blue Plus Individual plans, go to > Shop Plans > Individual

and Family Plans > See the covered drug list. Please use the following chart to write in your prescription drugs to

help you determine whether they are covered on this plan.

Prescription Drug

Drug Covered (Y/N)

Chart C. Pharmacy Network

A full list of pharmacies within the network can be viewed at > Shop Plans > Individual and

Family Plans > Search the pharmacy network. Please use the following chart to write in the pharmacies you use to

help you determine whether they are in or out of the plan’s network.

Pharmacy Network

In the plan network (Y/N)

Suitability Discussion And Worksheet - Minnesota Page 3