Medical Benefits
Basic Option Medical Benefits

Interested in knowing what you will pay for medical services under Basic Option? The chart below provides an at-a-glance overview of your benefits. Please keep in mind that you must use a Preferred provider to receive benefits. Except in certain situations, such as emergency care, benefits are not available for care that is performed by a Non-preferred provider.

Certain cost sharing amounts do not apply if Medicare is your primary coverage for medical services and you use a Preferred provider.

2009 Basic Option Benefits

What You Pay

Preventive Care

Services Basic Option Network Benefit *
  • Preventive screenings and related office visit charge, routine physical exams
  • Primary Care Provider - $25 office visit copayment
  • Specialists — $30 office visit copayment
  • Nothing for covered preventive screenings billed by your doctor
  • You pay 30% for drugs and supplies
  • Well Child Care — up to age 22, including routine physical examinations, routine hearing tests, laboratory tests, immunizations, and related office visits
  • Nothing for covered charges
  • Routine Dental Care
  • $20 office visit charge
    • 2 exams and cleanings per year
    • Annual x-rays
    • Sealants for children up to age 16

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Physician's Care

Services Basic Option PPO Benefit *
  • Surgical care

$100 copayment per surgeon
  • Home and office visits, second surgical opinions and consultations

$25 office visit charge for primary care provider

$30 office visit copayment for specialists

You pay 30% for drugs and supplies

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Maternity Care

Services Basic Option PPO Benefit *
  • Inpatient hospital and physician Care

Precertification is not required
  • Nothing for professional charges for pre-natal and post-natal care and delivery
  • $100 copayment per admission for inpatient hospital care

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Prescription Drug Coverage

Services Basic Option PPO Benefit *
  • Mail Service Pharmacy

Not offered
  • Retail Pharmacy

Up to an initial 34-day supply:

  • $10 copayment for generic drugs
  • $35 copayment for formulary brand name drugs
  • 50% coinsurance ($45 minimum) for non-formulary Non-preferred brand name drugs

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Hospital/Facility Care

Services Basic Option PPO Benefit *
  • Hospital inpatient — precertification required

$100 copayment per day up to $500 per admission for unlimited days
  • Outpatient facility care, excluding laboratory and x-ray services

$50 per day per facility copayment
  • Outpatient facility care, laboratory and x-ray services

Nothing for covered charges
  • Outpatient surgery

$50 per day per facility copayment

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Accidental Injury/Emergency Care

Services Basic Option PPO Benefit *
  • Accidental injury care — emergency room

$75 copayment
  • Medical emergency — emergency room

$75 copayment
  • Accidental injury and medical emergency — physician care

$30 copayment for preferred urgent care center

$30 copayment for preferred specialists office visit

$25 for preferred primary care provider office visit

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Chiropractic Care

Services Basic Option PPO Benefit *
  • Spinal Manipulations

Up to 20 spinal manipulations per year:

$25 copayment

Other Services

Services Basic Option PPO Benefit *
  • Catastrophic Services

100% payment level begins after you pay $5000 out-of-pocket in coinsurance and copayment expenses

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* Under Basic Option, benefits are not available for care that is performed by a Non-preferred provider, except in certain situations such as emergency care.

For a complete description of these benefits, refer to the 2009 Service Benefit Plan brochure (RI-71-005)