BlueEdge^SM 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 Deductible
$1,250	√
$1,750	√
$2,600	√
$3,500	√
$5,000		√
Individual Out-of-Pocket Expense Limit	Annual deductible plus $3,0001	Annual deductible
Preventive Care Services (benefits covered as defined by national guidelines)	100%	100%
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.