BlueEdge^SM

Health Savings Account (HSA)
Compatible Plans

BlueEdge^SM Individual HSA Plan Comparison Chart

Benefit Highlight	BlueEdge^SM Individual HSA¹	BlueEdge^SM Individual HSA 5000¹
Participating providers Participating Providers The preferred providers covered at 100% of eligible benefits.	PPO Network 90% of IL doctors; over 200 IL hospitals
Individual Deductible Annual deductible The amount you must pay before your plan begins paying.
$1,100	√
$1,750	√
$2,600	√
$3,500	√
$5,000		√
Individual Out-of-Pocket Expense Limit Out-of-pocket expense limit The maximum amount you will have to pay per year in addition to any applicable deductibles.	Annual deductible plus $3,000¹	Annual deductible
Well-Adult Care	You pay 0% or 20%	You pay 0%
Well-Child Care	You pay 0% or 20%	You pay 0%
Coinsurance Coinsurance The percentage you pay for services after your deductible and applicable copayments are met.	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%
	Outline of Coverage	Outline of Coverage

1. The individual out-of-pocket expense plus individual deductible can not exceed $5,000.

Note: the above chart highlights key plan differences and is not intended to be a comprehensive benefit summary. For a complete benefit summary, please click on each plan’s Outline of Coverage.