BlueEdgeSM Individual HSA
Health Savings Account Compatible Insurance Plans
Print
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 Deductible | |||
| $1,200 | √ | √ | |
| $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. Prior Authorization/Step Therapy Requirements: Before receiving coverage. |
||
Outline of Coverage  |
Outline of Coverage |
Outline of Coverage |
|
