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Basic Option Medical Benefits

Interested in knowing what your out-of-pocket costs will be 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 Preferred providers to receive benefits. Except in certain situations, such as emergency care, benefits are not available for care that is performed by Non-preferred providers.

Certain cost-sharing amounts do not apply if Medicare is your primary coverage for medical services and you use one of our Preferred providers.

Outlined below is a summary of the benefits provided under Basic Option. For a complete description of Basic Option benefits, refer to the Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005).

2014 Basic Option Benefits

You Pay

PPA = Preferred Provider Allowance

Preventive Care

ServicesBasic Option Network Benefit *
- You Pay

Preventive care services for adults age 22 and older including the preventive services recommended under the Affordable Care Act . Services include but are not limited to: 

  • Visits or exams for preventive care, including a history and risk assessment, chest X-ray, EKG, urinalysis, CBC, fasting lipid profile, cholesterol tests and metabolic and general health panel tests
  • Preventive screenings: Pap smears, mammograms, colorectal cancer tests , prostate cancer tests, STD screenings, genetic counseling in certain situations, and related office visits
  • Nothing for covered charges

Routine immunizations for adults age 22 and older [as licensed by the U.S. Food and Drug Administration (FDA)], limited to:

  • Hepatitis (Types A and B) for patients with increased risk or family history
  • Herpes Zoster (shingles)*
  • Human Papillomavirus (HPV)*
  • Influenza (flu)*
  • Measles, Mumps, Rubella
  • Meningococcal*
  • Pneumococcal* 
  • Tetanus-diphtheria, pertussis booster (one every 10 years)
  • Varicella

*Many Preferred retail pharmacies participate in our vaccine network.  Review pharmacy benefits for our coverage of these vaccines when provided by pharmacies in the vaccine network.

  • Nothing for covered charges

Preventive care services for children up to age 22, including preventive services recommended under the  Affordable Care Act. These services include but are not limited to visits or exams for preventive care, routine hearing and vision screenings, laboratory tests, immunizations, and nutrition counseling.

  • Nothing for covered charges

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Professional Provider's Care

ServicesBasic Option PPO Benefit * - You Pay
  • Surgical care
  • $150 copayment per performing surgeon in an office setting; $200 copayment per performing surgeon in other settings
  • Office visits, consultations, and second surgical opinions
  • $25 copayment per  visit for primary care provider
  • $35 copayment per visit  for specialist
  • You pay 30% PPA for drugs and supplies
  • Outpatient physical, occupational and speech therapy. Benefits are limited to 50 visits per person per calendar year for physical, occupational, or speech therapy or a combination of all three.
  • $25 copayment per visit for primary care provider
  • $35 copayment per visit for specialist

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Maternity Care

ServicesBasic Option PPO Benefit * - You Pay
  • Maternity care services, including pre-natal care, delivery, and postpartum care
  • Nothing for covered charges
  • Inpatient hospital/facility care

Precertification is not required for routine delivery

  • Nothing for professional charges for prenatal and postnatal care and delivery
  • $175 per admission copayment
  • Inpatient professional care
  • Nothing for covered charges

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Prescription Drug Coverage

ServicesBasic Option PPO Benefit * - You Pay
  • Preferred Retail Pharmacy
  • Tier 1 (generics): $10 copayment

  • Tier 2 (Preferred brand name): $45 copayment

  • Tier 3 (Non-preferred brand name): 50% coinsurance with a $55 minimum
    Tiers 1, 2, and 3 cover up to a 30-day supply, or up to 90-day supply for additional copayments

  • Tier 4 (Preferred specialty drugs): $60 copayment (30-day supply)

  • Tier 5 (Non-preferred specialty drugs): $80 copayment (30-day supply)
    Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.

  • Specialty Pharmacy
  • Tier 4 (Preferred specialty drugs): $50 copayment (30-day supply); $140 copayment (90-day supply)

  • Tier 5 (Non-preferred specialty drugs): $70 copayment (30-day supply); $195 copayment (90-day supply)
    90-day supply may only be obtained after 3rd fill

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Hospital/Facility Care

ServicesBasic Option PPO Benefit * - You Pay
  • Inpatient Hospital/Facility - Precertification is required
  • $175 copayment per day up to $875 per admission for unlimited days
  • Outpatient facility care, excluding diagnostic tests and laboratory services
  • $100 per day per facility copayment 
  • You may be responsible for paying a $150 copayment per day per facility if other diagnostic services are billed in addition to the services listed here.
  • You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. 
  • Outpatient facility care for diagnostic tests such as EEGs, ultrasounds, x-ray services  
  • $40 copayment per day per facility
  • Outpatient facility care for diagnostic tests such as MRIs, CT scans, Nuclear medicine, Sleep studies  
  • $150 copayment per day per facility
  • Outpatient facility care, laboratory
  • Nothing for covered charges
  • Outpatient facility care for drugs, medical devices, and durable medical equipment
  • 30% PPA

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Accidental Injury/Emergency Care

ServicesBasic Option PPO Benefit * - You Pay
  • Accidental injury or medical emergency - emergency room
  • $125 copayment
  • Accidental injury or medical emergency - urgent care
  • $50 copayment
  • Accidental injury and medical emergency - physician care  
  • $25 copayment per visit for preferred primary care provider
  • $35 copayment per visit for preferred specialist

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Manipulative Treatment

ServicesBasic Option PPO Benefit - You Pay

Manipulative treatment performed by a Doctor of Osteopathy (D.O.), Doctor of Medicine (M.D.), or Doctor of Chiropractic (D.C.) when the provider is practicing within the scope of his/her license, limited to:

  • Osteopathic manipulative treatment of any body region
  • Chiropractic spinal and/or extra-spinal manipulative treatment

$25 copayment per visit

Note: Benefits are limited to 20 manipulations per calendar year.

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Mental Health and Substance Abuse

ServicesBasic Option PPO Benefit - You Pay
  • Inpatient Hospital/Facility - Precertification is required
  • $175 copayment per day up to $875 per admission for unlimited days
  • Outpatient Hospital/Facility Care
  • $25 copayment per day per facility
  • Inpatient Professional Care
  • Nothing for covered professional visits
  • Outpatient Professional Care
  • $25 copayment per visit

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Other Services

ServicesBasic Option PPO Benefit * - You Pay

Catastrophic out-of-pocket maximum (Please refer to Section 4 in the Service Benefit Plan brochure  (R 71-005) for charges applied to this benefit.) 

100% payment level begins after you pay $5,500 (Self Only) or $7,000 (Self and Family) out-of-pocket in eligible coinsurance and copayment expenses

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

Page last updated: January 14, 2014

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