| Network |
See Provider |
See Provider |
| Application |
Blue Traditional Plan 2 Application |
Blue Traditional Plan 2 Application |
| Brochure |
Blue Traditional Plan 2 Brochure |
Blue Traditional Plan 2 Brochure |
| Copay |
N/A |
N/A |
| Office Visit |
Subject to deductible and coinsurance. |
Subject to deductible and coinsurance. |
| Deductible |
$500 Individual, $1,000 Family |
$500 Individual, $1,000 Family |
| Coinsurance |
80% |
80% |
| Coinsurance Limit |
Includes deductible:$2,500 Individual, $5,000 Family |
Includes deductible:$2,500 Individual, $5,000 Family |
| Out-of-Pocket Maximum |
Includes deductible:$2,500 Individual, $5,000 Family |
Includes deductible:$2,500 Individual, $5,000 Family |
| Lifetime Maximum |
$5,000,000 maximum per member |
$5,000,000 maximum per member |
| Prescription Drugs |
Retail (30-day supply): - Tier 1 - $15 per prescription.
- Tier 2 - $30 per prescription.
- Tier 3 - $60 per prescription.
- Tier 4 - 25% per prescription ($2,500 out-of-pocket maximum).
Mail Service (90-day supply): - Tier 1 - $30 per prescription.
- Tier 2 - $75 per prescription.
- Tier 3 - $150 per prescription.
- Tier 4 - 25% per prescription ($2,500 out-of-pocket maximum).
|
Retail (30-day supply): - Tier 1 - 50% with a minimum of $60, no maximum
- Tier 2 - 50% with a minimum of $60, no maximum
- Tier 3 - 50% with a minimum of $60, no maximum
- Tier 4 - 50% with a minimum of $60, no maximum
Mail Service (90-day supply): Not covered. |
| Emergency Room |
Subject to deductible and coinsurance. |
Subject to deductible and coinsurance. |
| Adult Preventative Care |
Subject to deductible and coinsurance. $300 calendar-year maximum. |
$500 maximum from birth to 12 months, $150 maximum from age 1 to age 9 per calendar year. |
| Child Preventative Care |
$500 maximum from birth to 12 months, $150 maximum from age 1 to age 9 per calendar year. |
$500 maximum from birth to 12 months, $150 maximum from age 1 to age 9 per calendar year. |
| Lab / X-Ray |
Subject to deductible and coinsurance. |
Subject to deductible and coinsurance. |
| Maternity |
Not Covered. You may purchase benefits for maternity at an additional cost. See Brochure for Optional Maternity Rider. |
Not Covered. You may purchase benefits for maternity at an additional cost. See Brochure for Optional Maternity Rider. |
| Physical Therapy |
Subject to deductible and coinsurance; Physical Therapy and Manipulation Therapy limited to 20 visits per person per calendar year. |
Subject to deductible and coinsurance; Physical Therapy and Manipulation Therapy limited to 20 visits per person per calendar year. |
| Skilled Nursing |
Subject to deductible and coinsurance; limited to 90 days per person per calendar year. |
Subject to deductible and coinsurance; limited to 90 days per person per calendar year. |
| Home Health Care |
Subject to deductible and coinsurance. Maximum visits per benefit period: 60 visits. |
Subject to deductible and coinsurance. Maximum visits per benefit period: 60 visits. |
| Mental Health |
Behavioral Health - Non-Biologically Based Mental Illness and Substance Abuse limits apply. Biologically based Mental Illnesses are covered the same as any other illness and limits do not apply. |
Behavioral Health - Non-Biologically Based Mental Illness and Substance Abuse limits apply. Biologically based Mental Illnesses are covered the same as any other illness and limits do not apply. |
| Hospital Care |
Subject to deductible and coinsurance. |
Subject to deductible and coinsurance. |
| Optional Benefits |
Blue Traditional Plan 2 |
Blue Traditional Plan 2 |