Health Check HSA
Health Savings Account Compatible Plan
|Benefit Highlight||Health Check HSA|
|Participating Providers||Blue Choice PPO Network
Blue Traditional Network
|Individual Out-of-Pocket Expense Limits||$3,000 - $5,000|
|Family Out-of-Pocket Expense Limits||$6,000 - $10,000|
The percentage you pay for services after deductible and applicable copayments are met.
You pay 0-40% after deductible
|Optional Maternity Coverage||Available|
|Optional Dental Coverage||Coverage available from BlueCare Dental PPO|
|Prescription Drugs||You pay 0-30% after deductible for in-network pharmacies|
|Prescription Drug Utilization/ Benefit Management Programs (for policies with effective dates on or after 1/1/2012)||Dispensing Limits: Benefits include coverage limits on certain medications. These limits are based on approved guidelines.
Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSOK and/or certain criteria must be met.
Specialty Pharmacy Program: Specialty medications must be received through the preferred Specialty Pharmacy Provider.
Reminder about coverage for self-administered specialty medications
Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay the share plus the difference in cost.