BlueEdgeSM Individual HSA
Health Savings Account (HSA) Compatible Plans
BlueEdgeSM Individual HSA Plan Comparison Chart
(Participating Provider Coverage Shown1)
|Benefit Highlight||BlueEdgeSM Individual HSA2||BlueEdgeSM Individual HSA 50002|
|Participating providers||Two provider network options: PPO Network, 90% of IL doctors;
over 200 IL hospitals, or BlueChoice® Network3
|Individual Out-of-Pocket Expense Limit||Annual deductible plus $3,0001||Annual deductible|
|Preventive Care Services
(benefits covered as defined by national guidelines)
|Coinsurance||You pay 0% or 20%||You pay 0%|
|Optional Maternity Coverage Coinsurance||You pay 0% or 20%||You pay 0%|
|Prescription Drugs||You pay 0% or 20%||You pay 0%|
|Prescription Drug Utilization/ Benefit Management Programs (for policies with effective dates on or after 1/1/2012)||Dispensing Limits: Benefits include coverage limits on certain 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.
Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, your usual share plus the difference in cost.
Prior Authorization/Step Therapy Requirements: Before receiving coverage.
|Outline of Coverage||Outline of Coverage|
1. Benefits reduced when non-participating providers are used. This is a summary of highlights only. Please refer to the Outline of Coverage for each plan for additional details.
2. The individual out-of-pocket expense plus individual deductible can not exceed $5,000.
3. The BlueChoice Network allows you to save on premiums and the cost of covered services when you use a contracting BlueChoice hospital, doctor or specialist. You do not need to select a primary care physician or obtain a referral to see a specialist.