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Blue Options HSA®

Plan summary

Preferred provider organization (PPO) Plan

Blue Options HSASM
Our high-deductible health plan with a tax-advantaged savings account for qualified medical expenses

Blue Options HSA provides lower premiums and savings as much as 34% off Blue
Advantage, giving you the ability to take control of your health care costs.¹ Blue Options
HSA combines a high-deductible health plan (HDHP) with a health savings account
(HSA), which enables you to pay for qualified medical expenses tax-free.^{2, 3} Out-ofpocket
maximums protect you from high-dollar medical costs. And, your HSA is
portable. Any unused balance rolls over at the end of the year.

With Blue Options HSA, you can choose your own doctor from our largest provider
network in the state. Preventive care services are covered at 100%, including routine
physical exams and screening tests, and well-baby and well-child care.⁴ Generic drugs
coverage is unlimited and brand-name drugs include a $2,000 combined in- and out-ofnetwork
maximum (per person, per benefit period).

The HSA is automatically included with the health plan if you choose Mellon Trust as the
fund administrator. Mellon includes a convenient debit card at no charge, and HSA
contributions and withdrawals are tax-free. ^{2, 3}

To be eligible for Blue Options HSA, you must be a North Carolina resident, under age
65, medically eligible, and not eligible for Medicare. Individual or family plans are
available. You can also select maternity coverage for an extra charge when you first
purchase a policy, renew a policy (if the policy has been in effect for at least six months),
or if you have a family status change, such as marriage.⁵

 

1 Blue Cross and Blue Shield of North Carolina Internal Data, 2009: Based on Blue Advantage $2,500
deductible with 80% coinsurance and Blue Options HSA $2,000 deductible with 80% coinsurance. Pricing
is for a single male, age 40-44, residing in Wake County.

2 BCBSNC does not administer your HSA and is not affiliated with your HSA custodian or administrator.
Your HSA custodian is Mellon Trust of New England, N.A.

3 Withdrawals are tax free only if used for qualified medical expenses. See www.irs.gov for specific
regulations.

4 Includes in-network annual routine physical exam, well-baby and well-child care and certain
immunizations and screenings. Other covered services may be subject to deductible and coinsurance.
Members who receive covered services out-of-network may be required to pay the difference between the
provider's actual charge and the BCBSNC allowed amount, in addition to the coinsurance amount.

5 Maternity coverage is offered through Blue Advantage at an additional rate.
Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield
Association. SM Mark of the Blue Cross and Blue Shield Association. SM1 Marks of Blue Cross and
Blue Shield of North Carolina.