| SUMMARIES | HSA Advantage Plan | Signature Plan | ||||
|---|---|---|---|---|---|---|
| BlueSelect Plus Network | BlueSelect Plus Network | |||||
| Health System Network | In-Network | Out-of-Network | Health System Network | In-Network | Out-of-Network | |
| ANNUAL DEDUCTIBLE | ||||||
| Single | $1,500 | $3,000 | $6,000 | $400 | $1,500 | $2,000 |
| Family | $3,000 | $6,000 | $12,000 | $800 | $3,000 | $4,000 |
| OUT-OF-POCKET MAXIMUM | ||||||
| Single | $4,000 | $4,000 | $19,800 | $4,000 | $4,000 | $10,500 |
| Family | $8,000 | $8,000 | $39,600 | $8,000 | $8,000 | $21,000 |
| Member coinsurance | 10% | 30% | 40% | 10% | 30% | 40% |
| OFFICE VISIT | ||||||
| Primary care (in-office or virtual visit) | Ded+10% coins | Ded+30% coins | Ded+40% coins | $20 copay | $30 copay | Ded+40% coins |
| Specialist (in-office or virtual visit) | Ded+10% coins | Ded+30% coins | $40 copay | $60 copay | ||
| Routine preventive care | Covered at 100% | Covered at 100% | Covered at 100% | Covered at 100% | ||
| Outpatient therapy (speech, hearing, physical, occupational) | Ded+10% coins | Ded+30% coins | $40 copay | Ded+30% coins | ||
| Urgent care | Ded+10% coins | Ded+30% coins | $40 copay | $60 copay | ||
| INPATIENT/OUTPATIENT SERVICES | ||||||
| Emergency department | Ded+10% coins | Ded+30% coins | Ded+30% coins* | Ded+10% coins | Ded+30% coins | Ded+30% coins* |
| Inpatient hospital services | Ded+40% coins | Ded+40% coins | ||||
| Outpatient hospital services | ||||||
| High-tech radiology services (MRI, CT, PET scan) | ||||||
*To ensure access to emergency care, coinsurance will be applied after the member meets the deductible for in-network care.
