BasicBlue^®

Hospitalization Only Plan

BasicBlue^SM Plan Benefit Highlights Chart

Benefit Highlight	BasicBlue^SM
Participating providers Participating Providers The preferred providers covered at 100% of eligible benefits.	Use ANY doctor; more than 200 hospitals
Individual Deductible Annual deductible The amount you must pay before your plan begins paying.
$500	√
$1,000	√
$2,500	√
Individual Out-of-Pocket Expense Limit Out-of-pocket expense limit The maximum amount you will have to pay per year in addition to any applicable deductibles.	1,000
Well-Adult Care	Not Covered
Well-Child Care	Not Covered
Coinsurance Coinsurance The percentage you pay for services after your deductible and applicable copayments are met.	You pay 20%
Optional Maternity Coverage Coinsurance	Not Available
Prescription Drugs	Not Covered
	Outline of Coverage

Note: the above chart highlights key benefit highlights and is not intended to be a comprehensive benefit summary. For a complete benefit summary, please click on the Outline of Coverage.