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Blue HSA Gold

Calendar Year Deductible $1,600 individual; $3,200 Family
Out-of-Pocket Maximum 
$4,000 individual; $8,000 family
Primary Care Office Visit
Covered at 90%; Subject to calendar year deductible
Specialist Office Visit Covered at 90%; Subject to calendar year deductible
Telephone and Online Video Consultations You pay $40 per consultation.
Outpatient Surgery Covered at 90%; Subject to calendar year deductible
Emergency Room Covered at 90%; Subject to 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
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
Covered at 90%; Subject to calendar year deductible