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BlueEdge^SM Individual HSA

Health Savings Account Compatible Insurance Plans

BlueEdge^SM 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	BlueEdge^SM Individual HSA (75/60)	BlueEdge^SM Individual HSA (90/70)	BlueEdge^SM Individual HSA (100/100)
Participating Provider	BlueChoice^® or BlueCard^®
Individual Deductible
$1,250	√	√
$1,750	√	√
$2,500	√	√
$3,500			√
$5,000			√
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

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