HealthPlan Express - Benefit Detail

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Plan Benefit Summary

Company/Plan Name	Personal Blue HSA Plan 5
Deductible
In-Network	$5,000 Per Family, Per Benefit Period
Out-Network	$5,000 Per Family, Per Benefit Period
Maximum Family Deductible	1 Per Family, Per Benefit Period
Coinsurance
In-Network	100%
Out-Network	60/40% to $12,500
Maximum Out-Of-Pocket Coinsurance
In-Network	$5,000 including Deductible
Out-Network	$10,000 including Deductible
Maximum Benefit	$2,000,000 lifetime maximum
Physician Office Visit
In-Network	Subject to Deductible & Coinsurance
Out-Network	Subject to Deductible & Coinsurance
Outpatient Lab & X-Ray
In-Network	Subject to Deductible & Coinsurance
Out-Network	Subject to Deductible & Coinsurance
Outpatient Preventive Care
In-Network	Subject to Deductible & Coinsurance
Out-Network	Subject to Deductible & Coinsurance
Prescription Drugs
Generic	Subject to Deductible & Coinsurance
Brand Name(formulary)	Subject to Deductible & Coinsurance
Brand Name(Non-formulary)	Subject to Deductible & Coinsurance
Outpatient Surgery
In-Network	Subject to Deductible & Coinsurance
Out-Network	Subject to Deductible & Coinsurance
Emergency Room
In-Network	Subject to Deductible & Coinsurance
Out-Network	Subject to Deductible & Coinsurance
Maternity Prenatal/Post Natal
In-Network	Optional Maternity Coverage Available (not quoted)
Out-Network	Optional Maternity Coverage Available (not quoted)
Inpatient Benefits
Hospitalization
In-Network	Subject to Deductible & Coinsurance
Out-Network	Subject to Deductible & Coinsurance
Surgical
In-Network	Subject to Deductible & Coinsurance
Out-Network	Subject to Deductible & Coinsurance
Maternity
In-Network	Optional Maternity Coverage Available (not quoted)
Out-Network	Optional Maternity Coverage Available (not quoted)
Rate Guarantee	None
Optional Benefits
Supplemental Accident	Not Available
24 Hour Coverage	Included in plan (not an optional benefit). Injuries or diseases not paid by worker?s compensation will be considered.
Other	Not Available

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IMPORTANT NOTICES AND DISCLAIMERS

To be considered for reimbursement, insurers require that expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits, unless you use a PPO/Network, as well as determinations of medical necessity.

This Benefit Comparison is intended as preliminary information only. The company provided (product specific) brochure contains important details concerning the benefits, limitations, exclusions and renewability of each plan. Be sure to download the brochure before applying. Refer to the policy as the binding authority for all terms and provisions of coverage. The rates provided are intended to be accurate but may change based on a number of factors including your medical history. The rates and terms of a policy may be changed by the insurance company with proper notification (and subject to any necessary regulatory approval). The rates shown are based on preferred underwriting criteria, if applicable.

Company Brochure

More details and variations in benefits for your state are in the company specific brochure and/or Outline of Coverage, which you can access by clicking the download brochure link above. Please do so before you apply. Alternatively, you may request this information be mailed to you.

Association Plans

Certain products available through some insurance companies require membership in an association which may be separate and distinct form the health plan/insurer. Details on membership and any fees are described in the company specific brochures.

Blue Cross and Blue Shield of South Carolina is an Independent Licensee of the Blue Cross and Blue Shield Association.

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