Compare Benefit Option Header Image

Compare Benefit Options

Through the Blue Cross and Blue Shield Service Benefit Plan, you can choose to receive coverage from Standard Option or Basic Option. There are a few key differences to consider. 

  1. While Basic Option requires that you use Preferred providers to receive benefits, you can go outside of the network with Standard Option. 
  2. Standard Option has a calendar year deductible, while Basic Option does not.
  3. You will pay a copayment amount for most of the care you receive under Basic Option. Under Standard Option, your out-of-pocket costs include copayment and coinsurance amounts.


What You Pay When You Use Preferred Providers

Outlined below is a summary of the Service Benefit Plan benefits. All benefits are subject to the definitions, limitations and exclusions set forth in the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure.

 

BENEFIT2014 STANDARD OPTION COVERAGE*2014 BASIC OPTION COVERAGE**
PHYSICIAN CARE
Office visits and outpatient consultations$20 per visit copayment for primary care provider
$30 per visit copayment for specialists
$25 per visit copayment for primary care provider
$35 per visit copayment for specialists
Routine exams and other preventive care servicesNothing for covered servicesNothing for covered services
Surgical services
Prior approval is required for certain surgical services
15% of the Plan allowance***
$150 copayment per performing surgeon in an office setting
$200 copayment per performing surgeon in another setting
HOSPITAL/FACILITY CARE
Hospital inpatient
Precertification is required
$250 per admission copayment for unlimited days$175 per day up to $875 per admission for unlimited days
Outpatient hospital/facility care15% of the Plan allowance***$100 per day facility copayment
PRESCRIPTION DRUGS
Certain prescription drugs require prior approval.
Mail Service Pharmacy ProgramTier 1 (generics)****: $15 copayment
Tier 2 (Preferred brand name): $80 copayment
Tier 3 (Non-preferred brand name): $105 copayment
Covers 22-90 day supply
Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs
Not a benefit
Preferred Retail Pharmacy ProgramTier 1 (generics)****: 20% coinsurance
Tier 2 (Preferred brand name): 30% coinsurance
Tier 3 (Non-preferred brand name): 45% coinsurance
Covers up to a 90-day supply
Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs when you use a Preferred Pharmacy
Tier 4 (Preferred specialty drugs): 30% coinsurance
Tier 5 (Non-preferred specialty drugs): 30% coinsurance
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.
Tier 1 (generics): $10 copayment
Tier 2 (Preferred brand name): $45 copayment
Tier 3 (Non-preferred brand name): 50% coinsurance with a $55 minimum
Covers 30-day supply, 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 ProgramTier 4 (Preferred specialty drugs): $35 copayment (30-day supply); $95 copayment (90-day supply)
Tier 5 (Non-preferred specialty drugs): $55 copayment (30-day supply); $155 copayment (90-day supply)
90-day supply can only be obtained after 3rd fill
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 can only be obtained after 3rd fill
LAB, X-RAY AND OTHER DIAGNOSTIC SERVICES
Diagnostic test (X-ray, blood work)
Imaging (CT/PET scans, MRIs)
15% of the Plan allowance***$0 copayment for laboratory tests, pathology services and EKGs
$40 copayment for diagnostic tests such as EEGs, ultrasounds and X-rays
$100 copayment for bone density tests, sleep studies, CT scans, MRIs, PET scans, angiography, genetic testing and nuclear medicine at a professional provider; $150 copayment at a hospital
EMERGENCY CARE
Accidental injury
Medical emergency
Accidental injury: Nothing for outpatient, hospital and physician services within 72 hours
Medical emergency: Regular benefits for physician and hospital care***; $40 copayment for urgent care center
Accidental injury and medical emergency:
$125 copayment for emergency room care
$50 copayment for urgent care center
Regular benefits for physician care
MATERNITY CARE
Inpatient/Outpatient hospital care
Precertification is not required for normal delivery
Physician care
Inpatient/Outpatient hospital care: No out-of-pocket expenses for covered services

Physician care including delivery and pre and postnatal care: No out-of-pocket expenses for covered services
Inpatient/Outpatient hospital care: $175 copayment per inpatient admission; No out-of-pocket expenses for outpatient covered services
Physician care including delivery and pre and postnatal care: No out-of-pocket expenses for covered services
DENTAL CARE
Routine dental careYour out-of-pocket expenses are limited to the balance after our payment up to the Maximum Allowable Charge$25 copayment per evaluation up to 2 per calendar year
Preventive care only
CHIROPRACTIC/OSTEOPATHIC MANIPULATIVE TREATMENT
Manipulative treatment$20 per visit copayment up to 12 manipulations per year$25 per visit copayment up to 20 manipulations per year
OTHER BENEFITS
Catastrophic benefits100% payment level begins after you pay $5,000 (Self Only) or $6,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses with Preferred providers100% 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

* When you use Non-preferred hospitals/facilities and professionals, your out-of-pocket expenses are greater. Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for details.

** Basic Option does not generally provide benefits for services rendered by Non-preferred providers.

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

**** Benefits for generic prescription drugs are different if you have Medicare Part B as your primary coverage.
Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for complete details.

Page last updated: November 19, 2013

More Resources