Benefit Plans
Fact Sheets

Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option — 2009

Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

Basic Option does not provide benefits when you use Non-preferred providers. For a list of the exceptions to this requirement, see refer to the 2009 Service Benefit Plan Brochure. There is no deductible for Basic Option.

Basic Option Benefits You Pay Brochure 
Page
Medical services provided by physicians:    
  • Diagnostic and treatment services provided in the office

PPO: $25 per office visit for primary care physicians and other health care professionals; $30 per office visit for specialists

Non-PPO: You pay all charges

 29-31
Services provided by a hospital:    
  • Inpatient

PPO: $100 per day up to $500 per admission

Non-PPO: You pay all charges

 66-68
  • Outpatient

PPO: $50 per day per facility

Non-PPO: You pay all charges

 69-71
Emergency benefits:    
  • Accidental injury

PPO: $75 copayment for emergency room care; $30 copayment for urgent care

Non-PPO: $75 copayment for emergency room care

 76, 79-80
  • Medical emergency
 Same as for accidental injury 76, 79-80
Mental health and substance abuse treatment

In-Network (PPO): Regular cost-sharing, such as $20 office visit copayment (prior approval required); $100 per day up to $500 per inpatient admission

Out-of-Network (Non-PPO): You pay all charges

 81-87
Prescription drugs

Retail Pharmacy Program:

  • PPO: $10 generic/$35 formulary brand-name per prescription/50% coinsurance ($45 minimum) for non-formulary brand-name drugs. 34-day maximum supply on initial prescription; up to 90 days for refills with 3 copayments
  • Non-PPO: You pay all charges
 88-95
Dental care

PPO: $25 copayment per evaluation (exam, cleaning, and X-rays); most services limited to 2 per year; sealants for children up to age 16; $25 copayment for dental services required due to accidental injury; regular benefits for covered oral and maxillofacial surgery

Non-PPO: You pay all charges

 55, 96-97, 101
Special features: Flexible benefits option; online customer and claims service; 24-hour nurse line; services for deaf and hearing impaired; Web accessibility for the visually impaired; travel benefit/services overseas; health support programs; and Healthy Families Program 102-103

Protection against catastrophic costs

(your catastrophic protection out-of-pocket maximum)

 Nothing after $5,000 (PPO) per contract per year; some costs do not count toward this protection 21-22