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HSA Eligible Plans
In-Network Benefits
Benefit Description Protect HSA $1,500 Protect HSA $2,500 Protect HSA $2,850

Annual Deductible

$1,500 per member*
$3,000 per family**

$2,500 per individual*
$5,000 per family**

$2,850 per member*
$5,650 per family**

Annual Out-of-Pocket Maximum

$4,500 per member*
$9,000 per family**

$2,500 per individual*
$5,000 per family**

$5,500 per member*
$11,000 per family**

Lifetime Maximum Benefit

$5,000,000
($2,000,000 cal. year max.)

$5,000,000
($2,000,000 cal. year max.)

$5,000,000
($2,000,000 cal. year max.)

Office Visits

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Other Professional Services

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Emergency Care

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Inpatient Hospital Services and Surgical Facilities

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Other Professional Services

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Well Woman Care

Not subject to the deductible
30% of negotiated fee, 1 visit/year

Not subject to the deductible, 100% plan paid. 1 visit/year

Not subject to the deductible
30% of negotiated fee, 1 visit/year

Well Baby Care

30% of negotiated fee after deductible

Not subject to the deductible, 100% plan paid.

30% of negotiated fee after deductible

Preventive Care (Ages 7 & Up) 1 Physical Per Year Deductible Does Not Apply

Plan pays up to $250, then you pay balance at 30% of the negotiated rate

Plan pays first $250 of covered expense, which is not subject to the deductible. Plan pays 100% of remaining charges after deductible is met

Plan pays up to $250, then you pay balance at 30% of the negotiated rate

Inpatient Nervous and Mental

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Outpatient Nervous and Mental Professional Services Day Care

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Inpatient Substance Abuse

30% of negotiated fee after deductible,

100% paid after deductible

30% of negotiated fee after deductible,

Outpatient Substance Abuse

30% of negotiated fee after deductible,

100% paid after deductible

30% of negotiated fee after deductible,

Physical Therapy, Occupational Therapy, Chiropractic Care

30% of negotiated fee after deductible,
25 visits/year

100% paid after deductible, max. 25 visits/year (combined with out-of-network visits)

30% of negotiated fee after deductible,
25 visits/year

Acupuncture

30% of negotiated fee after deductible.
Plan pays up to $60/visit after deductible,
max. 12 visits/year

100% paid after deductible. Plan pays up to $60/visit, max. 12 visits/year (combined with out-of-network visits)

30% of negotiated fee after deductible.
Plan pays up to $60/visit,
max. 12 visits/year

Durable Medical Equipment

30% of negotiated fee after deductible

100% paid after deductible

30% of negotiated fee after deductible

Skilled Nursing Facility

30% of negotiated fee after deductible,
100 days/year

100% paid after deductible, up to 100 days per year (combined in/out-of-network)

30% of negotiated fee after deductible,
100 days/year

Hospice Care

30% of negotiated fee after deductible,
up to the $5,000 lifetime max.

100% paid after deductible,
up to $5,000 lifetime maximum

30% of negotiated fee after deductible,
up to the $5,000 lifetime max.

Home Healthcare

30% of negotiated fee after deductible,
90 visits/year

100% paid after deductible max. 90 visits/year (combined in/out of network)

30% of negotiated fee after deductible,
90 visits/year
Prescription Drugs

Prescription Deductible

No separate deductible

No separate deductible

No separate deductible

Participating Pharmacies (30-day supply)

30% of negotiated drug fee after deductible

Plan pays 100% of negotiated drug fee after deductible

30% of negotiated drug fee after deductible

Self-Administered Injectable Drugs (excluding Insulin)
Retail (30-day supply)
Mail Order (60-day supply) Anthem Blue Cross NextRX Only

30% of negotiated drug fee after deductible

Plan pays 100% of negotiated drug fee after deductible

30% of negotiated drug fee after deductible

Mail Order (60-day supply) Anthem Blue Cross NextRX Only
Note: Some specialty drugs are available only through
Anthem Blue Cross’ Specialty Rx mail order program

30% of negotiated drug fee after deductible

Plan pays 100% of negotiated drug fee after deductible

30% of negotiated drug fee after deductible
Out-of-Network Benefits

Annual Deductible

No separate deductible, Out-of-Network benefits are included in the annual deductible

No separate deductible, Out-of-Network benefits are included in the annual deductible

No separate deductible, Out-of-Network benefits are included in the annual deductible

Annual Out-of-Pocket Maximum

No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max.

$5,000 per individual*
$10,000 per family**
(Separate in-/out-of-network Out-of-Pocket Maximums)

No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max.

Office Visits

Plan pays 50% of negotiated fee after deductible

Plan pays 70% of negotiated fee after deductible

Plan pays 50% of negotiated fee after deductible

Inpatient Hospital Services - Contracting Hospital

Plan pays 50% of negotiated fee, up to a max. of $540 per day after deductible

Plan pays 70% of negotiated fee after deductible, up to a maximum of $650 per day

Plan pays 50% of negotiated fee, up to a max. of $540 per day after deductible

Mental and Nervous - Inpatient

Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible

Plan pays 70% of negotiated fee after deductible, up to a maximum of $650 per day

Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible

Mental and Nervous - Outpatient

Plan pays 50% of negotiated fee after deductible

Plan pays 70% of negotiated fee after deductible, up to a maximum of $380 per day

Plan pays 50% of negotiated fee after deductible

Substance Abuse - Inpatient

Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible

Plan pays 70% of negotiated fee after deductible, up to a maximum of $650 per day

Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible

Substance Abuse - Outpatient

Plan pays 50% of negotiated fee after deductible

Plan pays 70% of negotiated fee after deductible, up to a maximum of $380 per day

Plan pays 50% of negotiated fee after deductible
Prescription Drugs

Prescription Deductible

No separate deductible

No separate deductible

No separate deductible

Mail Order

Not covered

Not covered

Not covered

Retail Pharmacies (30-day supply)

Plan pays 50% of the negotiated drug fee after deductible. Member pays any excess charges.

Plan pays 70% of the negotiated drug fee after deductible. Member pays any excess charges.

Plan pays 50% of the negotiated drug fee after deductible. Member pays any excess charges.

Self-Administered Injectable Drugs
(excluding Insulin) Mail order not covered

Plan pays 70% of negotiated drug rate after deductible. Member pays any excess charge where self-injectable drug price exceeds negotiated drug rate

Plan pays 70% of negotiated drug rate after deductible. Member pays any excess charge where self-injectable drug price exceeds negotiated drug rate

Plan pays 70% of negotiated drug rate after deductible. Member pays any excess charge where self-injectable drug price exceeds negotiated drug rate

 

*Individual Coverage refers to a subscriber without covered dependents. Individual subscribers are subject to the Individual Deductible and Individual Out-of-Pocket Maximum.

**Family Coverage refers to a subscriber and covered dependents. Benefits will not be paid for any family member until the full Family Deductible is met. Lilkewise, the Family Out-of-Pocket Maximum will not be considered met for any family member until the full Family Out-of-Pocket Maximum is met.