BlueDirect Gold 90 HSA Eligible ($2600 Deductible / $5 Preventive Drug List)

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

drug list

PPO

Gold

Deductible (per individual)	$2,600 /yr
Deductible (per family)	$5,200 /yr
Max Out-of-Pocket (per individual)	$4,300 /yr
Max Out-of-Pocket (per family)	$8,600 /yr
Drug Deductible (per individual)	Included in Medical
Drug Deductible (per family)	Included in Medical
Drug Max Out-of-Pocket (per individual)	Included in Medical
Drug Max Out-of-Pocket (per family)	Included in Medical
Plan Type	PPO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	10% Coinsurance after deductible
Specialist Visit	10% Coinsurance after deductible
Emergency Room	10% Coinsurance after deductible
Inpatient Facility	10% Coinsurance after deductible
Inpatient Physician	10% Coinsurance after deductible

Drug Costs
Generic Drugs	10% Coinsurance after deductible
Preferred Brand Drugs	10% Coinsurance after deductible
Non-preferred Brand Drugs	10% Coinsurance after deductible
Specialty Drugs	20% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible

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