BlueEdge^SM Individual HSA provides different levels of out-of-pocket expense limits, deductibles and coinsurance to allow you to select the plan that best meets your budget. With BlueEdge^SM Individual HSA, here’s what you can expect:

• PPO benefits begin after you meet the deductible
• Coinsurance level determined by health insurance plan selection
• Individual deductibles ranging from $1,200 to $5,000*
• Individual maximum out-of-pocket expenses ranging from $3,000 to $5,000*
• Family deductibles ranging from $2,400 to $10,000*
• Family maximum out-of-pocket expenses ranging from $6,000-$10,000*
• Copayments ranging from 75–100 percent of allowable amount after calendar year deductible for office visits (doctor consultation only) and emergency care
• Coinsurance — you pay 0–25 percent of allowable amount and the health insurance plan pays 75–100 percent of allowable amount*
• To see what your monthly payments would be, get a quick quote.

View the plan’s Outline of Coverage, which provides brief descriptions of the basic provisions of BlueEdge^SM Individual HSA, including costs and out-of-pocket expenses.

The information in the Outline of Coverage does not incorporate changes mandated by the Affordable Care Act of 2010 and is not reflective of the final benefits for products with an October 1, 2010, or later effective date. Please view the Important Notice Regarding Your Benefits for additional information regarding Affordable Care Act benefits.

• BlueEdge^SM Individual HSA Outline of Coverage .

• Important Notice Regarding Your Benefits 

* These cost ranges represent in-network coverage only. Out-of-network coverage costs can be significantly higher. Your greatest coverage and savings are realized when you use the services of participating providers within the network.

• BlueEdge^SM Individual HSA pays 75–100 percent of allowable amount and you pay 0–25 percent of allowable amount for covered expenses after you meet your deductible (in-network).
• In-network doctor’s office visits for routine physicals, immunizations and diagnostic tests are covered at 75–100 percent of the allowable amount, subject to deductible.
• Easy claims processing—no forms to file in most cases
• Emergency room visits are covered at 75–100 percent of allowable amount after calendar year deductible and coinsurance.
• The tax-favored advantages that come with a Health Savings Account*
• Access to online decision tools to help increase your knowledge of health issues and track your health care expenses

More Health Insurance Plan Details

It’s important to know the features of the health plan you are considering. Our Outline of Coverage document gives you brief descriptions of the basic details of our BlueEdge^SM Individual HSA health insurance plan, as well as details on renewability, exclusions and limitations.

The information in the Outline of Coverage does not incorporate changes mandated by the Affordable Care Act of 2010 and is not reflective of the final benefits for products with an October 1, 2010, or later effective date. Please view the Important Notice Regarding Your Benefits for additional information regarding Affordable Care Act benefits.

• BlueEdge^SM Individual HSA Outline of Coverage .

• Important Notice Regarding Your Benefits 

* Health Savings Accounts (HSAs) have tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products.

• Prescription drug coverage is included with this plan.
• Copayments for prescription drugs vary based on plan options you choose.
• If you take medications for birth control, high blood pressure, cholesterol or other long-term needs, you can also receive up to a 90-day supply at retail. In some cases, you'll pay less for the same amount of medication than at a retail pharmacy.
• View the Complete Prescription Drug List  to see if your prescriptions are included in the plan.

You can customize any BlueEdge^SM Individual HSA with the following option:

Dental Indemnity USA Plan Policy form # IND-DEN-2

The Individual Dental plan is available as an optional benefit with your Blue Cross and Blue Shield of Texas BlueEdge^SM Individual HSA health insurance plan. There is an additional premium.

Some highlights of Dental Indemnity USA coverage:

• Coverage can be used to provide dental benefits to an individual, spouse, children or any combination of dependents. Dental coverage will correlate with the type of health plan selected.
• A $50 deductible for each insured person for each calendar year.
• Maximum deductible amount of $150 for family coverage each calendar year.
• Deductibles do not apply to oral exams, cleaning, fluoride treatments, sealants and X-rays
• Covered individuals must be enrolled for 12 months before receiving dental benefits in these categories; major restorative, periodontics, prosthetics and orthodontics.

See the Dental Indemnity USA Outline of Coverage  for dental plans for more details on benefits and policies.