BlueEdgeSM Individual HSA
Health Savings Account (HSA) Compatible Plans
Print
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 Deductible | ||
| $1,200 | √ | |
| $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. 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.
