Traditional Blue^SM

A Budget-Conscious Product with
the ability to choose ANY doctor

Traditional Blue^SM Plan Benefit Highlights Chart

Benefit Highlight	Traditional Blue^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.
$250	√
$500	√
$1,000	√
$2,500	√
$5,000	√
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	You pay 20%
Coinsurance Coinsurance The percentage you pay for services after your deductible and applicable copayments are met.	You pay 0% or 20%
Optional Maternity Coverage Coinsurance	Physician Covered Services; You pay 20% Hospital Covered Services; You pay 0% or 20%
Prescription Drugs	You pay 20%
	Outline of Coverage
	Check your Provider Status

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.