BlueEdgeSM Individual HSA
Health Savings Account Compatible Insurance Plans
BlueEdgeSM Individual HSA Plan Comparison Chart
This chart is a representation of Network benefits. Please refer to the Outline of Coverage for Out-of-Network benefits
|Benefit Highlight||BlueEdgeSM Individual HSA (75/60)||BlueEdgeSM Individual HSA (90/70)||BlueEdgeSM Individual HSA (100/100)|
|Participating Provider||BlueChoice® or BlueCard®|
|Individual Out of Pocket Expense Limit||$3000||$3000||Equal to deductible amount selected|
|Preventive Care||100% of Allowable Amount (no Deductible)||100% of Allowable Amount (no Deductible)||100% of Allowable Amount (no Deductible)|
|Childhood Immunizations||100% to 6 years of age||100% to 6 years of age||100% to 6 years of age|
|Coinsurance||Plan pays 75% of allowable amount and member pays 25%||Plan pays 90% of allowable amount and member pays 10%||Plan pays 100% of allowable amount and member pays 0%|
|Optional Dental Coverage Deductible||$50||$50||$50|
|Prescription Drugs||Medical deductible plus copay: $10 generic, $50 preferred, $65 non-preferred||Medical deductible plus copay: $10 generic, $50 preferred, $65 non-preferred||100% after medical deductible|
|Prescription Drug Deductible||None||None||None|
|Prescription Drug Utilization/ Benefit Management Programs||Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost.
For policies with effective dates on or after 3/1/2012:
Dispensing Limits: Benefits include coverage limits on certain quantities of medications.
Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy Provider.
View the Specialty Pharmacy Program List which includes a reminder about coverage for self-administered specialty medications.
Prior Authorization/Step Therapy Requirements: Before receiving coverage.
|Outline of Coverage||Outline of Coverage||Outline of Coverage|