Health insurance costs include monthly payments, individual deductibles, drug coverage deductibles, out-of-pocket expenses, copayments, and coinsurance. For the Health Check HSA plan, here’s what you can expect:

• Deductibles ranging from $1,500 to $5,000 for individuals $3,000 to 10,000 for families
• Coinsurance ranging from 0 – 40 percent of allowable charges, depending on network provider used and your deductible level
• Choice of maximum out-of-pocket expense ranging from $3,000 to $5,000 for individuals and $6,000 to $10,000 for families
• Preferred member rates for non-tobacco users (must be smoke-free for at least 12 months)
• To view your specific costs, get a quick quote.

Health Check HSA is a flexible and reliable health care plan with options for individuals and families. Best of all the money you put into your HSA account is tax deductible.¹ Some additional features of this plan include:

• Access to a broad network of contracting doctors, hospitals and health care providers in all 50 states, and in more than 200 countries
• HealthCheck HSA pays from 60 – 100 percent after deductible is met, depending on network provider used and your deductible level
• Plan pays 70 – 100 percent of allowable charges for prescriptions after deductible is met, depending on network pharmacy used and your deductible level
• Benefits for preventive care services covered
• No lifetime maximum
• Access to Blue Care Connection^®, a series of services and programs geared towards improving your health

1 BCBSOK is not an expert on tax or investment advice, so please be sure to talk to a qualified tax and/or investment advisor for details on HSA accounts. To be eligible to establish and maintain a Health Savings Account, you must meet the requirements in the regulations established by the Internal Revenue Service. In order to establish a Health Savings Account: you cannot be claimed as a dependent under another person’s income tax return; and you cannot be covered by a health plan, other than a qualifying high deductible health plan, which provides any of the same benefits as this Health Check HSA plan.

• Benefits are subject to pre-existing condition limitations for covered individuals age 19 and over only.
• No benefits will be provided for pre-existing conditions for a period of 12 months after coverage becomes effective. This applies to covered individuals age 19 and over only.
• This provision applies to any condition or any charges relating to a condition existing during the 12 months immediately before the effective date of coverage.

There are a couple of ways that you can customize your Health Check HSA plan, including certain types of add-on coverage and insurance. The following options are available for this plan.

Maternity

Health Check HSA offers an option of enrolling with maternity benefits. Coverage must be in effect for at least 365 days or more before benefits are available.

Dental

BlueCare Dental PPO can be added for a few more dollars a month. Key features of this plan include:

• Benefits effective immediately for check-ups, cleanings and other preventive services
• Deductible of $50 per member during benefit period; $150 maximum per family
• Maximum benefit of $1,500 per covered individual
• Plan pays 50 – 100 percent of allowable charges, depending on type of service, at participating dentists
• Plan pays 30 – 70 percent of allowable charges, depending on type of service, at out-of-network dentists
• 20 percent discount for orthodontic services at participating dentists, up to a maximum savings of $1,000
• To learn more about BlueCare Dental PPO, including costs, view the Enrollment Guide above.

• Prescription drug coverage is included with this plan.
• Coinsurance for prescription drugs vary based on plan options you choose.
• You have the option to order your prescription drugs through the mail with our 90-Day Supply Program.
• Prescription Drug Utilization/Benefit Management Programs are being added to policies with effective dates on or after 1/1/2012. See Compare Plans Chart for more information.