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Blue HSA Bronze

Calendar Year Deductible $6,450 individual; $12,900 family
Out-of-Pocket Maximum
$6,450 individual; $12,900 family
Physician Visits Covered at 100%; Subject to the calendar year deductible
Telephone and Online Video Consultations
You pay $40 per consultation
Outpatient Surgery
Covered at 100%; Subject to the calendar year deductible
Emergency Room Covered at 100%; Subject to the calendar year deductible
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
Prescription Drugs






Tier 1: You pay 0% after you meet the calendar year deductible / Tier 2:
You pay 0% after you meet the calendar year deductible / Tier 3: You pay
0% after you meet the calendar year deductible / Tier 4: You pay 0% after
you meet the calendar year deductible / Tier 5 (preferred specialty): You
pay 0% after you meet the calendar year deductible / Tier 6 (nonpreferred
specialty): You pay 0% after you meet the calendar year deductible /
Generic drugs are mandatory when available
Pediatric Routine Dental Cleaning and
Yearly Eye Exam

Routine Dental Cleaning and Yearly Eye Exam: you pay 0% after you meet
the calendar year deductible
Covered at 100%; Subject to the calendar year deductible
Covered at 100%; Subject to the calendar year deductible
Covered at 100%; Subject to the calendar year deductible