Benefit Plans - Standard Option

Standard Option Medical Benefits

Want to know what you will pay for medical services under Standard Option? Standard Option allows you the freedom to receive care from a Preferred provider or a Non-preferred provider, whichever you choose. The chart below provides an at-a-glance overview of your medical benefits.

Calendar year deductible

The annual deductible for Standard Option is $300 per member per calendar year or $600 per family each calendar year. The amount you pay for your calendar year deductable does not accumulate toward your Catastrophic Protection Out-Of-Pocket Maximum. Certain deductibles and coinsurance amounts do not apply to you if Medicare is your primary coverage for medical services.

On limited occasions, such as for certain drugs requiring prior approval, you will need to file a claim for services received from Preferred providers.

Outlined below is a summary of the Service Benefit Plan benefits provided under Standard Option. For a complete description of the Standard Option benefits, refer to the 2010 Service Benefit Plan brochure (RI 71-005).

2010 Standard Option Benefits

What You Pay

You can jump to a particular benefits type by using the drop down menu below:

Preventive Care

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
Preventive screenings: Pap smears, mammograms, stool tests for blood, prostate specific antigen tests, cholesterol tests, sigmoidoscopies and related office visit charge	$20 office visit copayment for primary care provider $30 office visit copayment for specialists Nothing for covered preventive screenings Members can obtain one co-pay waiver for this service by completing the Blue Health Assessment after Jan. 1, 2010	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance (PA) for covered tests The preventive screening office visit is not covered
Routine physical exams, including a history and risk assessment, chest X-ray, EKG, urinalysis, CBC and metabolic and general health panel tests annually	$20 office visit copayment for primary care provider $30 office visit copayment for specialists Members can obtain one co-pay waiver for this service by completing the Blue Health Assessment after Jan. 1, 2010	All charges
Routine immunizations [as licensed by the U.S. Food and Drug Administration (FDA)], limited to: Hepatitis immunizations (Types A and B) for patients with increased risk or family history Herpes Zoster (shingles) vaccines* Human Papillomavirus (HPV) vaccines* Influenza (one each flu season) and pneumococcal vaccines* H1N1 Influenza (Swine) vaccines* Meningococcal vaccines* Tetanus-diphtheria (Td) booster — once every 10 years	Adults — $20 office visit copayment for primary care provider $30 office visit copayment for specialists Nothing for immunizations Children to Age 22 — Member pays nothing (no deductible)	Adults — $30 co-pay and the difference between our allowance and the billed amount for seasonal influenza and/or H1N1 vaccine 35% of Plan allowance plus any difference between our allowance and the billed amount for other vaccines in this benefit Children to Age 22 — Member pays nothing, but is responsible for any difference between Plan allowance and billed amount.
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	Nothing up to the Plan Allowance
Dental Care for services listed in Section 5(g) of the 2010 Service Benefit Plan brochure (RI 71-005) fee schedule	Your out-of-pocket costs are limited to a Maximum Allowable Charge (MAC) Benefits paid according to the fee schedule outlined in the 2010 Service Benefit Plan brochure	Benefits paid according to the fee schedule in the 2010 Service Benefit Plan brochure You are responsible for the balance up to the Billed charges
Jump 4 Health	Children age 5 through 17 who meet certain Body Mass Index (BMI) criteria may be eligible to participate in the Jump 4 Health Weight Management Program and receive up to 4 nutritional counseling visits at no cost when they use Preferred providers	N/A

Physician's Care

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
Inpatient services, including surgical and medical care	Subject to the calendar year deductible (Individual or Family) 15% of the Preferred Provider Allowance	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance, plus any difference between our allowance and the billed amount
Outpatient surgery and related diagnostic tests such as X-rays, laboratory tests and machine diagnostic tests **	Subject to the calendar year deductible (Individual or Family) 15% of the Preferred Provider Allowance	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance, plus any difference between our allowance and the billed amount
Home and office visits, second surgical opinions, outpatient consultations and medical emergency care	$20 office visit copayment for primary care provider $30 office visit copayment for specialists	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance, plus any difference between our allowance and the billed amount
Outpatient physical, occupational and speech therapy benefits are limited to 75 visits per person per calendar year for physical, occupational, or speech therapy or a combination of all three.	$20 office visit copayment for primary care provider $30 office visit copayment for specialists	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Services

Standard Option PPO Benefit

Standard Option Non-PPO Benefit *

Inpatient services, including surgical and medical care

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Outpatient surgery and related diagnostic tests such as X-rays, laboratory tests and machine diagnostic tests **

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Home and office visits, second surgical opinions, outpatient consultations and medical emergency care

$20 office visit copayment for primary care provider

$30 office visit copayment for specialists

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Outpatient physical, occupational and speech therapy benefits are limited to 75 visits per person per calendar year for physical, occupational, or speech therapy or a combination of all three.

$20 office visit copayment for primary care provider

$30 office visit copayment for specialists

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Maternity Care

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
Physician care, including delivery and pre-and post-natal care	Nothing for covered charges	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance, plus any difference between our allowance and the billed amount
Inpatient hospital and physician Care Precertification is not required	Nothing for covered charges	$350 per admission copayment at Member and Non-member hospitals Additional 35% of the Plan Allowance, plus any difference between our allowance and the billed amount at Non-member hospitals

Services

Standard Option PPO Benefit

Standard Option Non-PPO Benefit *

Physician care, including delivery and pre-and post-natal care

Nothing for covered charges

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Inpatient hospital and physician Care

Precertification is not required

Nothing for covered charges

$350 per admission copayment at Member and Non-member hospitals

Additional 35% of the Plan Allowance, plus any difference between our allowance and the billed amount at Non-member hospitals

Prescription Drug Coverage

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
Prescription Drugs Mail Service Pharmacy	$10 copayment for generic drugs $65 copayment for brand name drugs	There is no benefit
Prescription Drugs Retail Pharmacy (brand name and generic drugs)	20% of the Allowance at the time of purchase	100% of the Billed charges at the time of purchase. You must file a claim to receive 55% of the Average Wholesale Price (AWP) as your reimbursement

Services

Standard Option PPO Benefit

Standard Option Non-PPO Benefit *

Prescription Drugs Mail Service Pharmacy

$10 copayment for generic drugs

$65 copayment for brand name drugs

There is no benefit

Prescription Drugs Retail Pharmacy (brand name and generic drugs)

20% of the Allowance at the time of purchase

100% of the Billed charges at the time of purchase. You must file a claim to receive 55% of the Average Wholesale Price (AWP) as your reimbursement

Hospital/Facility Care

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
Hospital inpatient room and board and other inpatient hospital services Precertification required	Unlimited days $200 per admission copayment	Unlimited days $350 per admission copayment 35% of the Plan Allowance at Non-member hospitals, plus any difference between our allowance and the billed amount ***
Hospital/Facility care – outpatient surgery	15% of the Preferred Provider Allowance	35% of the Plan Allowance, plus any difference between our allowance and the billed amount
Hospital/Facility care - outpatient services including medical emergency care, diagnostic tests, renal dialysis, radiation therapy, and chemotherapy.	Subject to the calendar year deductible (Individual or Family) 15% of the Preferred Provider Allowance	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance, plus any difference between our allowance and the billed amount
Outpatient physical, occupational and speech therapy (when performed and billed by a hospital or freestanding ambulatory facility). Benefits are limited to 75 visits per person per calendar year for physical, occupational, or speech therapy or a combination of all three.	$20 office visit copayment for primary care provider $30 office visit copayment for specialists	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance, plus any difference between our allowance and the billed amount

Accidental Injury/Emergency Care

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
Covered charges in connection with and within 72 hours after an accidental injury at a facility or in a physician's office. NOTE: For services received after 72 hours, regular medical and outpatient hospital benefits apply.	Nothing for covered charges	Nothing for covered charges at Member facilities Any difference between the Plan Allowance and the billed amount at Non-member facilities.

Services

Standard Option PPO Benefit

Standard Option Non-PPO Benefit *

Covered charges in connection with and within 72 hours after an accidental injury at a facility or in a physician's office.

NOTE: For services received after 72 hours, regular medical and outpatient hospital benefits apply.

Nothing for covered charges

Nothing for covered charges at Member facilities

Any difference between the Plan Allowance and the billed amount at Non-member facilities.

Chiropractic Care

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
One office visit per calendar year One set of X-rays per calendar year Spinal manipulations Note: Benefits may be available for other covered services you receive from chiropractors in medically underserved areas. See page 12 in the 2010 Service Benefit Plan brochure (R 71-005) for additional information.	Preferred: $20 copayment per visit (No deductible) Participating: 35% of the Plan allowance Non-participating: 35% of the Plan allowance, plus any difference between our allowance and the billed amount Note: Benefits are limited to 12 manipulations per calendar year. Note: Office visits, X-rays, and spinal manipulations that you pay for while meeting your calendar year deductible count toward the appropriate benefit limit.	Preferred: $25 copayment per visit Note: Benefits are limited to 20 manipulations per calendar year. Participating/Non-participating: You pay all charges

Services

Standard Option PPO Benefit

Standard Option Non-PPO Benefit *

One office visit per calendar year
One set of X-rays per calendar year
Spinal manipulations

Note: Benefits may be available for other covered services you receive from chiropractors in medically underserved areas. See page 12 in the 2010 Service Benefit Plan brochure (R 71-005) for additional information.

Preferred: $20 copayment per visit (No deductible)

Participating: 35% of the Plan allowance

Non-participating: 35% of the Plan allowance, plus any difference between our allowance and the billed amount

Note: Benefits are limited to 12 manipulations per calendar year.

Note: Office visits, X-rays, and spinal manipulations that you pay for while meeting your calendar year deductible count toward the appropriate benefit limit.

Preferred: $25 copayment per visit

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

Participating/Non-participating: You pay all charges

Mental Health and Substance Abuse

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
Inpatient Hospital Precertification required	$200 per admission copayment Unlimited days	Member: $350 per admission copayment for unlimited days (No deductible) Non-member: $350 per admission copayment for unlimited days, plus 35% of the Plan allowance, and any remaining balance after our payment (No deductible)
Outpatient Facility Care **	Subject to the calendar year deductible (Individual or Family) 15% of the Preferred Provider Allowance	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance at Member facilities and Non-member facilities
Inpatient Professional Care	Subject to the calendar year deductible (Individual or Family) 15% of the Preferred Provider Allowance	Member facility: $350 per admission copayment for unlimited days (No deductible) Non-member facility: $350 per admission copayment for unlimited days, plus 35% of the Plan allowance, and any remaining balance after our payment (No deductible) Participating professional: 35% of the Plan allowance Non-participating professional: 35% of the Plan allowance, plus any difference between our allowance and the billed amount
Outpatient Professional Care *	$20 office visit copayment for primary care provider $30 office visit copayment for specialists	Subject to the calendar year deductible (Individual or Family) 35% of the Plan Allowance

Services

Standard Option PPO Benefit

Standard Option Non-PPO Benefit *

Inpatient Hospital

Precertification required

$200 per admission copayment

Unlimited days

Member: $350 per admission copayment for unlimited days (No deductible)

Non-member: $350 per admission copayment for unlimited days, plus 35% of the Plan allowance, and any remaining balance after our payment (No deductible)

Outpatient Facility Care **

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance at Member facilities and Non-member facilities

Inpatient Professional Care

Subject to the calendar year deductible (Individual or Family)

15% of the Preferred Provider Allowance

Member facility: $350 per admission copayment for unlimited days (No deductible)

Non-member facility: $350 per admission copayment for unlimited days, plus 35% of the Plan allowance, and any remaining balance after our payment (No deductible)

Participating professional: 35% of the Plan allowance

Non-participating professional: 35% of the Plan allowance, plus any difference between our allowance and the billed amount

Outpatient Professional Care *

$20 office visit copayment for primary care provider

$30 office visit copayment for specialists

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance

* For Standard Option PPO Benefit: Members must call for prior approval before receiving any outpatient professional or outpatient facility care from preferred providers. See page 81 or the 2010 Service Benefit Plan Brochure (R 71-005)

Other Services

Services	Standard Option PPO Benefit	Standard Option Non-PPO Benefit *
Catastrophic protection (Please refer to Section 4 in the 2010 Service Benefit Plan brochure (R 71-005) for charges applied to this benefit.)	100% payment level begins after you pay $5000 out-of-pocket in coinsurance, copayment and deductible expenses	100% payment level begins after you pay $7000 out-of-pocket in coinsurance, copayment and deductible expenses

PPA = Preferred Provider Allowance, the amount accepted as payment in full by most Preferred professionals and pharmacies.

Calendar Year Deductible = One $300 deductible per member per calendar year, $600 family limit each calendar year. Certain deductibles and coinsurance amounts do not apply to you if Medicare is your primary coverage for medical services (it pays first).

On limited occasions, such as for certain drugs requiring prior approval, you will need to file a claim for services received from Preferred providers.

* When you use Non-member facilities and Non-participating professionals, you are also responsible for the difference between the provider's charge and our payment. And when rendered by a Non-PPO provider, treatment of mental health and substance abuse is covered differently. Under certain circumstances your out-of-pocket expenses may be limited. See Section 10 of the 2010 Service Benefit Plan brochure.

** Certain diagnostic cancer tests are paid differently.

*** Emergency admissions to Non-member hospitals are paid at 100% of the Plan Allowance after the $300 per admission copayment.

This is a summary of the Service Benefit Plan benefits. For a complete description, see the 2010 Service Benefit Plan brochure (RI-71-005).

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