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Blue HSA Gold

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Calendar Year Deductible: $1,600 self-only or $3,200 maximum for the entire family

Out-of-Pocket Maximum: $4,000 self-only or $8,000 for the entire family

(Once you reach the maximum, you will pay nothing for eligible, in-network expenses for the rest of the year.)

    YOU PAY WE PAY
Physicians visits logo PHYSICIAN VISITS
Primary Care Physician and Specialist		 10% after you meet the calendar year deductible 90% after you meet the calendar year deductible
OUTPATIENT SURGERY 10% after you meet the calendar year deductible 90% after you meet the calendar year deductible
EMERGENCY ROOM
For a medical emergency		 10% after you meet the calendar year deductible 90% after you meet the calendar year deductible
INPATIENT HOSPITAL CARE
Co-Pays vs Co-Insurance		 10% after you meet the calendar year deductible 90% after you meet the calendar year deductible
MATERNITY CARE
Physician Benefits		 10% after you meet the calendar year deductible 90% after you meet the calendar year deductible
MENTAL HEALTH
Office Visit or Consultation		 10% after you meet the calendar year deductible 90% after you meet the calendar year deductible
PRESCRIPTION DRUGS
Source+Rx 1.0 Drug List		 Tiers 1-6: 10% after you meet the calendar year deductible Tiers 1-6: 90% after you meet the calendar year deductible
OCCUPATIONAL, PHYSICAL AND SPEECH THERAPY
Up to 30 visits per year		 10% after you meet the calendar year deductible 90% after you meet the calendar year deductible
DIAGNOSTIC LAB 10% after you meet the calendar year deductible 90% after you meet the calendar year deductible
ROUTINE IMMUNIZATIONS
AND PREVENTIVE SERVICES
AlabamaBlue.com/PreventiveServices		 $0 100%
PEDIATRIC DENTAL & VISION
 
 Routine Dental Cleaning: $0 after you meet the calendar year deductible
Yearly Eye Exam: 10% after you meet the calendar year deductible		 Routine Dental Cleaning: 100% after you meet the calendar year deductible
Yearly Eye Exam: 90% after you meet the calendar year deductible

*Benefits listed apply to in-network services. In-Network services outside of Alabama may vary.