Blue HSA Bronze

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Calendar Year Deductible: $6,450 self only or $12,900 maximum for the entire family.

Out-of-Pocket Maximum: $6,450 self only or $12,900 for the entire family.
(Once you reach the maximum, you will pay nothing for eligible, in-network expenses for the rest of the year.)

IMPORTANT: This plan uses the Select Lab Network.

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

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