Compare 2012 Benefits

Standard Option

More Choices

More network providers means more choices. Our nationwide network of almost one million hospitals, physicians, pharmacies and other health care providers makes it easy to use a Preferred provider. And when you use a Preferred provider, the provider files the claim, payment is made to the provider and you are only responsible for any difference between our allowance and our payment. This is also true for Participating providers. You can choose to use Non-participating providers, but your out-of-pocket expenses will be higher than if you used Preferred or Participating providers.

EXAMPLE OF YOUR SAVINGS WHEN YOU USE PREFERRED PROVIDERS IN 2013*

DIAGNOSTIC TESTSPREFERRED PHYSICIANPARTICIPATING PHYSICIANNON-PARTICIPATING PHYSICIAN
Physician’s charge$250$250$250
Our allowance$100$100$100
We pay85% of our allowance or $8565% of our allowance or $6565% of our allowance or $65
Your coinsurance15% of our allowance or $1535% of our allowance or $3535% of our allowance or $35
Plus any difference up to the provider’s charge$0$0$150
YOUR TOTAL ESTIMATED PAYMENT$15$35$185

*Savings example assumes that the calendar year deductible was already satisfied.

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2013 Standard Option Benefits At-A-Glance

Certain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first). Please see the 2013 Service Benefit Plan brochure for more information. Brochure sections are identified for your reference.

PPA=Preferred Provider Allowance | PA=Plan Allowance | MAC=Maximum Allowable Charge

WHAT YOU PAY
SERVICES2013 STANDARD OPTION PPO BENEFIT2013 STANDARD OPTION NON-PPO BENEFIT*
PREVENTIVE CARE - BROCHURE SECTIONS 5(a) AND 5(h)
Preventive Screenings and related office visit charge, routine physical examsNothing for an annual physical and covered preventive screenings.35% PA**
Well Child Care up to age 22Nothing for covered charges.35% PA**
PHYSICIAN CARE - BROCHURE SECTIONS 5(a) AND 5(b)
Surgical Care15% PPA**35% PA**
Home and office visits, second surgical opinions and consultations$20 per visit copayment for primary care physician.
$30 per visit copayment for specialists.
35% PA**
MATERNITY CARE - BROCHURE SECTION 5(a)
Inpatient Hospital Care: Precertification not requiredNothing for covered charges.$350 per admission copayment plus 35% PA in Non-member hospitals.
Physician CareNothing for covered charges.35% PA**
HOSPITAL/FACILITY CARE - BROCHURE SECTION 5(c)
Hospital Inpatient: Precertification required$250 per admission copayment.$350 per admission copayment.
35% PA in Non-member hospitals.
Outpatient Facility Care15% PA**35% PA** plus any difference between billed charge and PA.
DENTAL CARE - BROCHURE SECTION 5(g)
Preventive Dental CareYour out-of-pocket expenses are limited to the balance after our payment up to the MAC.You are responsible for the balance after our payment, up to the billed charge.
ACCIDENTAL INJURY/MEDICAL EMERGENCY - BROCHURE SECTION 5(d)
Accidental Injury within 72 hours of accidentNothing for covered charges.Nothing for coverage charges. You pay any difference between our allowance and billed charge.
Medical Emergency/Facility careEmergency Room: 15%PPA**
Urgent Care Center: $40 copayment.
Emergency Room: 15%PA**
Urgent Care Center: 35% PA** plus any difference between billed charge and PA.
Medical Emergency/Physician care$20 per visit copayment for primary care physician.
$30 per visit copayment for specialists.
35% PA** plus any difference between billed charge and PA.
OTHER BENEFITS - BROCHURE SECTION 4
Catastrophic Benefits100% payment level begins after you pay $5000 out-of-pocket in coinsurance, copayment and deductible expenses.100% payment level begins after you pay $7000 out-of-pocket in coinsurance, copayment and deductible expenses.

*When you use Non-preferred facilities and professionals, your out-of-pocket expenses are greater and you generally pay any difference between our allowance and the billed amount. Please see Section 10 of the 2013 Service Benefit Plan brochure.

**Subject to one $350 deductible per member per calendar year, $700 family limit each calendar year.

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Page last updated: July 01, 2013

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