Blue HSA Gold Health Insurance Plan

Blue HSA Gold

Consider a Gold plan if you have regular prescriptions and use healthcare services often.

This plan requires a Health Savings Account and covers most of your eligible in-network expenses at 100% once you meet the calendar-year deductible.

Lower Premium

Lower Deductible

Calendar Year Deductible	$1,750 individual; $3,500 family
Out-of-Pocket Maximum	$6,000 individual; $12,000 family
Primary Care Office Visit	Plan pays 90%; Subject to the deductible
Specialist Office Visit	Plan pays 90%; Subject to the deductible
Telephone and Online Video Consultations	You pay $45 per consultation
Outpatient Surgery	Covered at 90%; Subject to calendar year deductible
Emergency Room	Covered at 90%; Subject to calendar year deductible
Pediatric Routine Dental Cleaning and Yearly Eye Exam	Routine Dental Cleaning: you pay 0% after you meet the calendar year deductible; Yearly Eye Exam: you pay 10% after you meet the calendar year deductible
Prescription Drugs	Tier 1: You pay 10% after you meet the calendar year deductible / Tier 2: You pay 10% after you meet the calendar year deductible / Tier 3: You pay 10% after you meet the calendar year deductible / Tier 4: You pay 10% after you meet the calendar year deductible / Tier 5 (preferred specialty): You pay 10% after you meet the calendar year deductible / Tier 6 (nonpreferred specialty): You pay 10% after you meet the calendar year deductible / Generic drugs are mandatory when available
Notes	This plan uses the Source+Rx 1.0 Prescription Drug List and the ValueONE Network, which does not include all major retail chains. Check the pharmacy network.