BlueEdgeSM Select HSA
(2-150 employees)
BlueEdge Select Health Savings Account (HSA) is a consumer-directed health plan that includes a Health Savings Account to help employees pay for medical expenses and meet the annual deductible. The chart below presents the different BlueEdge Select HSA plan design options and includes a comparison of in-network versus out-of-network benefits. Prescription drugs are covered at the medical coinsurance benefit noted in the chart below.
In-Network Benefits — 100% / 70% Coinsurance
| Coinsurance | Deductible (Individual/Family) | Out-of-Pocket Max* (Individual/Family) | Office Visit/ Emergency Room Benefit** |
|---|---|---|---|
| 100% | $1,200 / $2,400 | $2,400 / $4,800 | Covered at 100% / 90% |
| 100% | $1,500 / $3,000 | $3,000 / $6,000 | Covered at 100% / 90% |
| 100% | $2,500 / $5,000 | $2,500 / $5,000 | Covered at 100% / 100% |
| 100% | $2,500 / $5,000 Embedded |
$2,500 / $5,000 | Covered at 100% / 100% |
Out-of-Network Benefits
| Coinsurance | Deductible (Individual/Family) | Out-of-Pocket Max* (Individual/Family) |
|---|---|---|
| 70% | $2,400 / $4,800 | $4,800 / $9,600 |
| 70% | $3,000 / $6,000 | $6,000 / $12,000 |
| 70% | $5,000 / $10,000 | $5,000 / $10,000 |
| 70% | $5,000 / $10,000 Embedded |
$5,000 / $10,000 |
In-Network Benefits — 80% / 50% Coinsurance
| Coinsurance | Deductible (Individual/Family) | Out-of-Pocket Max* (Individual/Family) | Office Visit/ Emergency Room Benefit** |
|---|---|---|---|
| 80% | $1,200 / $2,400 | $2,400 / $4,800 | Covered at 80% / 80% |
| 80% | $1,500 / $3,000 | $3,000 / $6,000 | Covered at 80% / 80% |
| 80% | $2,500 / $5,000 | $5,000 / $10,000 | Covered at 80% / 80% |
| 80% | $2,500 / $5,000 Embedded |
$5,000 / $10,000 | Covered at 80% / 80% |
Out-of-Network Benefits
| Coinsurance | Deductible (Individual/Family) | Out-of-Pocket Max* (Individual/Family) |
|---|---|---|
| 50% | $2,400 / $4,800 | $4,800 / $9,600 |
| 50% | $3,000 / $6,000 | $6,000 / $12,000 |
| 50% | $5,000 / $10,000 | $10,000 / $20,000 |
| 50% | $5,000 / $10,000 Embedded |
$10,000 / $20,000 |
* The deductible is included in the out-of-pocket max
** The deductible must be met before the indicated benefits for office visit/emergency room applies
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