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.
2012 Basic Option Benefits
You Pay
You can jump to a particular benefits type by using the drop down menu below:
PPA = Preferred Provider Allowance
Preventive Care
| Services | Basic Option Network Benefit *
- You Pay |
|---|
| - Take the Blue Health Assessment
and receive a $35 payment card for eligible health expenses
- Complete three online coaching modules on Blue Health Connection and receive $15 on your payment card ($5 for each completed module)
- Take the Breathe smoking cessation coaching module and receive smoking cessation medication at no cost when you use a Preferred retail pharmacy
- You are entitled to a Diabetes Management Incentive Program if you indicate that you have diabetes through the Blue Health Assessment or the Care for Diabetes coaching module
|
| - Nothing for covered charges
|
- Preventive care services for children, up to age 22, including preventive services recommended under the Patient Protection and Affordable Care Act. Services include routine physical examinations, routine hearing tests, laboratory tests, immunizations, nutritional counseling, and related office visits
| - Nothing for covered charges
|
| - $25 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 * - You Pay |
|---|
| - $150 copayment per performing surgeon
|
- Office visits, home visits, second surgical opinions and consultations
| - $25 office visit copayment for primary care provider
- $35 office visit copayment for specialists
- You pay 30% PPA for drugs and supplies
|
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Maternity Care
| Services | Basic Option PPO Benefit * - You Pay |
|---|
- Inpatient hospital and physician care
Precertification is not required | - Nothing for professional charges for prenatal and postnatal care and delivery
- $150 per admission
|
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Prescription Drug Coverage
| Services | Basic Option PPO Benefit * - You Pay |
|---|
| Not offered |
| - Tier 1 (generic): $10 copayment for for a 34-day supply or $30 for a 90-day supply.
- Tier 2 (Preferred brand-name): $40 copayment for a 34-day supply or $120 for a 90-day supply.
- Tier 3 (Non-Preferred brand-name): 50% PPA ($50 minimum) for a 34-day supply or 50% PPA ($150 minimum) for a 90-day supply.
- Tier 4 (Specialty drug): $50 copayment for a 34-day supply or $150 for a 90-day supply for specialty drugs purchased at a Preferred retail pharmacy.
|
| - Tier 4 (Specialty drug): $40 copayment for a 34-day supply or $120 for a 90-day supply. Learn how to obtain prescriptions through our Preferred Specialty Pharmacy.
|
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Hospital/Facility Care
| Services | Basic Option PPO Benefit * - You Pay |
|---|
- Inpatient Hospital - Precertification is required
| - $150 copayment per day up to $750 per admission for unlimited days
|
- Outpatient facility care, excluding laboratory, EEG, ultrasounds, and x-ray services
| - $75 per day per facility copayment
|
- Outpatient facility care: EEG, ultrasounds, x-ray services
| |
- Outpatient facility care, laboratory
| - Nothing for covered charges
|
- Outpatient facility care for surgical services
| - $75 per day per facility copayment
|
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Accidental Injury/Emergency Care
| Services | Basic Option PPO Benefit * - You Pay |
|---|
- Accidental injury care - emergency room
| |
- Medical emergency - emergency room
| |
- Accidental injury and medical emergency - physician care
| - $50 copayment for preferred urgent care center
- $25 for preferred primary care provider office visit
- $35 copayment for preferred specialist office visit
|
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Chiropractic Care
| Services | Basic Option PPO Benefit * - You Pay |
|---|
- One office visit per calendar year
- One set of X-rays per calendar year
Note: Benefits may be available for other covered services you receive from chiropractors in medically underserved areas. See page 12 in the Service Benefit Plan brochure (R 71-005) for additional information. | |
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Manipulative Treatment
| Services | Basic 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
Note: Benefits may be available for other covered services you receive from chiropractors in medically underserved areas. See page 12 in the Service Benefit Plan brochure (R 71-005) for additional information. | $25 copayment per visit Note: Benefits are limited to 20 manipulations per calendar year. |
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Mental Health and Substance Abuse
| Services | Basic Option PPO Benefit - You Pay |
|---|
- Inpatient Hospital - Precertification is required
| - $150 copayment per day up to $750 per admission for unlimited days
|
| - $75 per day per facility copayment
|
- Inpatient Professional Care
| - Nothing for covered services
|
- Outpatient Professional Care
| |
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Other Services
| Services | Basic Option PPO Benefit * - You Pay |
|---|
Catastrophic Services | 100% payment level begins after you pay $5000 out-of-pocket in coinsurance and copayment expenses |
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