BlueEdgeSM Individual HSA
(Health Savings Account)

Policy Form Number: PPO-BLUEEDGE-INDL-HSA-1

General Benefits

In-Network Benefits Out-Of-Network Benefits
Highest Benefit Levels Lower Benefit Levels
Providers precertify care You must preauthorize hospital admissions and certain services
Usually no claim forms to file You may have to submit claims for reimbursement

Individual & Family Plans Only

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