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Standard Option Medical Benefits

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

Calendar year deductible

The calendar year deductible for Standard Option is $350 per member or $700 per family. For families of two, each family member must fully satisfy his or her individual deductible before the "family deductible" is considered met. Certain deductibles, copayments and coinsurance amounts do not apply if Medicare is your primary coverage for medical services.

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

2014 Standard Option Benefits

You Pay

Preventive Care

ServicesStandard Option PPO Benefit - You PayStandard Option Non-PPO 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 preventive screenings

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance for covered tests*

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 immunizations

Subject to the calendar year deductible (Individual or Family)

35% of Plan allowance*

Note: Your deductible and coinsurance amount are waived for Influenza vaccines billed by Participating and Non-participating providers

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

Subject to the calendar year deductible (Individual or Family)

35% of Plan allowance*

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Professional Provider's Care

ServicesStandard Option PPO Benefit - You PayStandard Option Non-PPO Benefit * - You Pay
  • 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*

  • Outpatient surgery and related diagnostic tests such as laboratory tests, pathology services, X-rays, and other imaging services

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*

  • Office visits, consultations, and second surgical opinions

$20 office visit copayment for primary care provider

$30 office visit copayment for specialist

35% of the Plan allowance (deductible applies)

  • 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 copayment per visit for primary care provider

$30 copayment per visit for specialist

Subject to the calendar year deductible (Individual or Family)

35% of the Plan allowance*

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Maternity Care

ServicesStandard Option PPO Benefit - You PayStandard Option Non-PPO Benefit * - You Pay
  • Maternity care services, including pre-natal care, delivery, and postpartum care

Nothing for covered charges

Subject to the calendar year deductible (Individual or Family)

35% of the Plan allowance* (deductible applies)

  • Inpatient hospital/facility care Precertification is not required for routine delivery

Precertification is not required

Nothing for covered charges

Unlimited days, $350 per admission copayment, plus 35% of the Plan Allowance*

  • Inpatient professional care

Nothing for covered charges

35% of the Plan Allowance* (deductible applies)

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Prescription Drug Coverage

ServicesStandard Option PPO Benefit - You PayStandard Option Non-PPO Benefit* - You Pay

Mail Service Pharmacy Program

Covers up to a 90-day supply

You pay nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs.

Up to a 90-day supply when you use Preferred Pharmacies. Nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs.

Tier 1: $15 copayment for generic drugs. If you have Medicare Part B as your primary coverage, you pay a $10 copayment.
Tier 2: $80 copayment for Preferred brand-name drugs.
Tier 3: $105 copayment for non-Preferred brand-name drugs.

After you have filled 30 brand-name drugs during the year, you pay a $50 copayment per brand-name drug filled for the remainder of the year.

Formulary
Prior Authorization

There is no benefit

Preferred Retail Pharmacy Program

Covers up to a 90-day supply when you use Preferred Retail Pharmacies to purchase Tier 1, Tier 2, or Tier 3 drugs.

You pay nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs.

Tier 1: 20% coinsurance for generic drugs. If Medicare Part B is your primary payer, you pay 15% coinsurance.
Tier 2: 30% coinsurance for Preferred brand-name drugs.
Tier 3: 45% coinsurance for non-Preferred brand-name drugs.
Tier 4: 30% coinsurance for Preferred specialty drugs
Tier 5: 30% coinsurance for Non-preferred specialty drugs

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.

Formulary
Prior Authorization

45% coinsurance, plus any difference between our allowance and the billed amount.

Specialty Pharmacy Program

Tier 4: $35 copayment for Preferred specialty drugs for up to a 30-day supply; $95 copayment for 90-day supply
Tier 5: $55 copayment for Non-preferred specialty drugs for up to a 30-day supply; $155 copayment for 90-day supply

90-day supply may only be obtained after 3rd fill

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Hospital/Facility Care

ServicesStandard Option PPO Benefit - You PayStandard Option Non-PPO Benefit * - You Pay
  • Inpatient Hospital/Facility room and board and other inpatient services

Precertification required

Unlimited days

$250 per admission copayment

Unlimited days, $350 per admission copayment, plus 35% of the Plan Allowance*

  • Outpatient Hospital/Facility care – including services such as surgery, medical emergency care, and 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*

  • 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*

  • 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 visit copayment

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

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Accidental Injury Care

ServicesStandard Option PPO Benefit - You PayStandard Option Non-PPO Benefit * - You Pay
  • Covered services provided at a hospital/facility or in a physician's office in connection with and within 72 hours after an accidental injury.

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

Nothing for covered services

Nothing for covered services. You may be responsible for any difference between the Plan Allowance and the billed amount.

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Manipulative Treatment

ServicesStandard Option PPO Benefit - You PayStandard Option Non-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

Preferred: $20 copayment per visit (No deductible)

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

Subject to the calendar year deductible (Individual or Family)

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

Note: Manipulations that you pay for while meeting your calendar year deductible count toward the appropriate benefit limit.

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

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Mental Health and Substance Abuse

ServicesStandard Option PPO Benefit - You PayStandard Option Non-PPO Benefit * - You Pay
  • Inpatient Hospital/Facility

Precertification required

$250 per admission copayment

Unlimited days

Unlimited days, $350 per admission copayment, plus 35% of the Plan Allowance*

  • Outpatient Hospital/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*

  • Inpatient Professional Care

Nothing for covered charges

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

  • Outpatient Professional Care

$20 copayment per visit

Subject to the calendar year deductible (Individual or Family)

35% of the Plan Allowance*

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Other Services

ServicesStandard Option PPO Benefit - You PayStandard Option Non-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 $5,000 (Self Only) or $6,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses

100% payment level begins after you pay $7,000 (Self Only) and $8,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses

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Calendar Year Deductible = One $350 deductible per member per calendar year, $700 family limit each calendar year.

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

* When you do not use a Preferred provider, you may be responsible for the difference between the Plan Allowance and the billed amount depending on the contracting status of the Non-PPO provider. Emergency admissions to Non-member hospitals are paid at 100% of the Plan Allowance after the $350 per admission copayment.

Page last updated: January 14, 2014

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