Medical Benefits
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. 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 2009 Service Benefit Plan brochure (RI 71-005).

2009 Standard Option Benefits

What You Pay

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 for each related office visit

Nothing for preventive screening tests

Subject to the calendar year deductible (Individual or Family)

30% 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 for the office visit

Nothing for related preventive screening tests

All charges
  • Influenza & Pneumonia Immunizations — See Section 5(a) of the 2009 Service Benefit Plan brochure (RI 71-005) for timing information

$20 office visit copayment

Nothing for immunizations

Subject to the calendar year deductible (Individual or Family)

30% of the Plan Allowance

The office visit charge associated with routine immunizations is not covered
  • 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

Your out-of-pocket costs are limited to a Maximum Allowable Charge (MAC)

Benefits paid according to the fee schedule outlined in the 2009 Service Benefit Plan brochure

Benefits paid according to the fee schedule in the 2009 Service Benefit Plan brochure

You are responsible for the balance up to the Billed charges

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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)

30% of the Plan Allowance
  • 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)

30% of the Plan Allowance
  • Home and office visits, second surgical opinions, outpatient consultations and medical emergency care

$20 per visit

Subject to the calendar year deductible (Individual or Family)

30% of the Plan Allowance
  • 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 for each visit

Subject to the calendar year deductible (Individual or Family)

30% of the Plan Allowance

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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)

30% of the Plan Allowance
  • Inpatient hospital and physician Care

Precertification is not required

Nothing for covered charges

$300 per admission copayment at Member and Non-member hospitals

Additional 30% of the Plan Allowance at Non-member hospitals

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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

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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

$300 per admission copayment

30% of the Plan Allowance at Non-member hospitals ***
  • Hospital/Facility care – outpatient surgery

15% of the Preferred Provider Allowance

30% of the Plan Allowance at Member facilities and Non-member facilities
  • 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)

30% of the Plan Allowance at Member facilities and Non-member facilities
  • 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 per visit

Subject to the calendar year deductible (Individual or Family)

30% of the Plan Allowance at Member facilities and Non-member facilities

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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.

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Chiropractic Care

Services Standard Option PPO Benefit Standard Option Non-PPO Benefit *
  • One office visit per year
  • One set of X-rays per year
  • Spinal Manipulations

Benefits are limited to 12 spinal manipulations per person per calendar year

$20 copayment per visit

Subject to the calendar year deductible (Individual or Family)

30% of the Plan Allowance

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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

$400 per day copayment at Member hospitals and Non-member hospitals

Up to 100 days per calendar year for mental conditions

28 days per lifetime for substance abuse
  • 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)

30% of the Plan Allowance at Member facilities and Non-member facilities

There is a maximum of 25 combined outpatient visits allowed per person per calendar year
  • Inpatient Professional 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)

40% of the Plan Allowance

100 days per person per calendar year for mental conditions
  • Outpatient Professional Care *

$20 copayment per visit

Treatment plan needed prior to your ninth outpatient visit of the calendar year

Subject to the calendar year deductible (Individual or Family)

40% of the Plan Allowance

There is a maximum of 25 combined outpatient visits allowed per person per calendar year

* 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 2009 Service Benefit Plan Brochure (R 71-005)

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Other Services

Services Standard Option PPO Benefit Standard Option Non-PPO 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

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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 2009 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 2009 Service Benefit Plan brochure (RI-71-005).