2007 Standard Option Benefits
At-A-Glance

The chart below provides an At-A-Glance benefit overview of your Standard Option coverage, so please take a few moments to review it and familiarize yourself with your benefits. For a complete description of benefits please refer to the 2007 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005) online or you can call your local Blue Cross and Blue Shield Plan at the number on the back of your ID card to request one.

Standard Option Benefits At-A-Glance
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		$15 for each related office visit Nothing for preventive screening tests		Subject to $250 calendar year deductible 25% Plan Allowance 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		$15 for the office visit Nothing for related preventive screening tests		Not a benefit
Influenza & Pneumonia Immunizations — See Section 5(a) of the 2007 Service Benefit Plan brochure for timing information		$15 office visit copayment Nothing for immunizations		Subject to $250 calendar year deductible 25% 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 for covered charges
Dental Care for services listed in Section 5(h) of the 2007 Service Benefit Plan brochure fee schedule		Your out-of-pocket costs are limited to a Maximum Allowable Charge (MAC) Benefits paid according to the fee schedule in the 2007 Service Benefit Plan brochure		Benefits paid according to the fee schedule in the 2007 Service Benefit Plan brochure You are responsible for balance up to Billed charges
Physician's Care
Services		Standard Option PPO Benefit		Standard Option Non-PPO Benefit *
Inpatient services, including surgical and medical care		Subject to $250 calendar year deductible 10% PPA		Subject to $250 calendar year deductible 25% Plan Allowance
Outpatient surgery and related diagnostic tests such as X-rays, laboratory tests and machine diagnostic tests **		Subject to $250 calendar year deductible 10% PPA		Subject to $250 calendar year deductible 25% Plan Allowance
Home and office visits, second surgical opinions, outpatient consultations and medical emergency care		$15 for the visit charge, with no deductible		Subject to $250 calendar year deductible 25% Plan Allowance
Outpatient physical, occupational and speech therapy Combined maximum of 75 visits per year per person		$15 for each visit		Subject to $250 calendar year deductible 25% Plan Allowance
Chiropractic Care
Services		Standard Option PPO Benefit		Standard Option Non-PPO Benefit *
Spinal manipulations		$15 copayment for each visit Up to 12 spinal manipulations per year per person		Subject to $250 calendar year deductible 25% Plan Allowance Up to 12 spinal manipulations per year per person
Maternity Care
Services		Standard Option PPO Benefit		Standard Option Non-PPO Benefit *
Inpatient hospital care - Precertification is not required		Nothing for covered charges		$300 per admission copayment 30% Plan Allowance at Non-member hospitals
Physician care including delivery and pre-and post-natal care		Nothing for covered charges		Subject to $250 calendar year deductible 25% Plan Allowance
Prescription Drugs
Services		Standard Option PPO Benefit		Standard Option Non-PPO Benefit *
Prescription Drugs Mail Service Pharmacy Up to a 90-day supply per prescription or refill		$10 copayment for generic drugs $35 copayment for brand name drugs		$10 copayment for generic drugs $35 copayment for brand name drugs
Prescription Drugs Retail Pharmacy (brand name and generic drugs) Up to a 90-day supply per prescription or refill		25% PPA at the time of purchase		100% of Billed charges at the time of purchase, file a claim, then receive 55% of Average Wholesale Price (AWP) as 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 $100 per admission copayment		Unlimited days $300 per admission copayment 30% Plan Allowance at Non-member hospitals ***
Hospital/Facility care - outpatient surgery		10% PPA		25% of 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 $250 calendar year deductible 10% PPA		Subject to $250 calendar year deductible 25% of Plan Allowance at Member facilities and Non-member facilities
Outpatient physical, occupational and speech therapy - combined maximum of 75 visits per year		$15 for each visit		Subject to $250 calendar year deductible 25% of Plan Allowance at Member facilities and Non-member facilities
Accidental Injury
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. (See the definition of accidental injury in Section 10 of the 2007 Service Benefit Plan brochure Includes outpatient medical care, diagnostic tests, and ambulance transportation		Nothing for covered charges		Any difference between the Plan Allowance and the billed amount
Mental Health And Substance Abuse
Services		Standard Option PPO Benefit		Standard Option Non-PPO Benefit *
Inpatient Hospital - Precertification required		In full after $100 per admission copayment Unlimited days		$400 daily copayment at Member hospitals and Non-member hospitals 100 days per calendar year for mental conditions 28 days per lifetime for substance abuse
Outpatient Facility Care		Subject to $250 calendar year deductible 10% PPA		Subject to the $250 calendar year deductible 25% Plan Allowance at Member facilities and Non-member facilities Combined total of 25 visits per calendar year
Inpatient Professional Care		Subject to $250 calendar year deductible 10% PPA		Subject to the $250 calendar year deductible 40% of Plan Allowance 100 days per calendar year for mental conditions 28 days per lifetime for substance abuse
Outpatient Professional Care		$15 copayment per visit Treatment plan needed prior to 9th visit		Subject to the $250 calendar year deductible 40% of Plan Allowance Combined total for outpatient visits of 25 visits per calendar year per patient
Other Services
Services		Standard Option PPO Benefit		Standard Option Non-PPO Benefit
Catastrophic Protection (Please refer to Section 4 in the 2007 Service Benefit Plan brochure for charges applied to this benefit.)		100% payment level begins after you pay $4000 out-of-pocket in coinsurance, copayment and deductible expenses		100% payment level begins after you pay $6000 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 $250 deductible per member per calendar year, $500 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 2007 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 2007 Service Benefit Plan brochure (RI-71-005).