2008 Standard And Basic Option
Benefits Comparison

This page provides a comparison summary of the Standard and Basic Option benefits for 2008. For a complete description of benefits please refer to the 2008 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.

What You Pay When You Use Network Providers
Preventive Care
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Adults: Preventive Screenings and related office visit charge, Routine Physical exams		$15 office visit copayment Nothing for covered preventive screenings		$20 office visit copayment for primary care provider $30 office visit copayment for specialists Covered preventive screenings are paid in full when billed by your doctor
Children: Preventive Care, including routine physical examinations, routine hearing tests, laboratory tests, immunizations and related office visits		Nothing for covered services		Nothing for covered services
Physician's Care
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Inpatient services, including surgery and medical care, and outpatient surgery		Subject to $300 calendar year deductible 10% PPA		$100 copayment per surgeon Nothing for other covered services
Home and office visits, second surgical opinions and consultations		$15 office visit copayment		$20 office visit copayment for primary care provider $30 office visit copayment for specialists
Outpatient physical, occupational and speech therapy		$15 for each visit Combined maximum of 75 visits per year per person		$20 copayment per visit for primary care provider $30 copayment per visit for specialists Combined maximum of 50 visits per year per person
Prescription Drugs
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Mail Service Pharmacy		Up to a 90-day supply $10 copayment for generic drugs $35 copayment for brand name drugs		No benefit
Retail Pharmacy		Up to a 90-day supply 25% PPA at the time of purchase (generic and brand name drugs)		Up to a 34-day initial supply, 90-day supply for 3 copays $10 copayment for generic drugs $30 copayment for formulary brand name drugs 50% coinsurance ($35 minimum) for Non-formulary Non-preferred brand name drugs
Hospital/Facility Care
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Hospital Inpatient — Precertification Required		Unlimited days $100 per admission copayment		Unlimited days $100 per day up to $500
Outpatient Facility Care, excluding laboratory and X-ray services		Subject to $300 calendar year deductible 15% PPA		$40 per day per facility copayment
Outpatient Facility, physical, occupational and speech therapy		$15 copayment per visit Combine maximum of 75 visits per year per person		$40 per visit Combine maximum of 50 visits per year per person
Outpatient Facility, laboratory and X-ray services		Subject to $300 calendar year deductible 15% PPA		Nothing
Outpatient Surgery		15% PPA		$40 copayment — facility $20 copayment — primary care provider $30 copayment — specialist
Emergency Care
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Accidental Injury — emergency room care and ambulance services		Nothing for covered charges for services rendered within 72 hours of the accident		$50 copayment — facility $20 copayment — primary care provider $30 copayment — specialist
Medical Emergency — facility care		Subject to $300 calendar year deductible 15% PPA		$50 copayment
Medical Emergency — physician care		$15 office visit copayment		$50 copayment — facility $20 copayment — primary care provider $30 copayment — specialist
Mental Health And Substance Abuse
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Outpatient professional services***		$15 office visit copayment		$20 office visit copayment
Chiropractic Care
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Spinal manipulations		Up to 12 spinal manipulations per year $15 copayment		Up to 20 spinal manipulations per year per person $20 copayment
Dental Care
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Routine Dental Care		Benefits paid according to fee schedule in the 2008 Service Benefit Plan brochure Your out-of-pocket costs are limited to a Maximum Allowable Charge (MAC)		$20 office visit copayment Benefits are available for 2 per year exams and cleanings, annual X-rays, and sealants for children up to age 16
Other Benefits
Benefit		Standard Option PPO Coverage *		Basic Option Coverage **
Catastrophic Benefits		100% payment level begins after you pay $4500 out-of-pocket in coinsurance, copayment and deductible expenses		100% payment level begins after you pay $5000 out-of-pocket in coinsurance and copayment expenses

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

Certain deductibles, copayments and coinsurance amounts do not apply if Medicare is your primary coverage for medical services (it pays first).

* When you use Non-member facilities and Non-participating professionals, your out-of-pocket expenses are greater under Standard Option. You are responsible for any deductible and coinsurance amounts as well as the difference between the provider's charge and our payment. When you use Member facilities and Participating professional providers, the coinsurance amount and benefit limitations may differ. The treatment of Mental Health and Substance Abuse is covered differently when you do not use a Preferred provider.

** Basic Option does not provide benefits for services rendered by Non-preferred providers, except in certain situations such as emergency care.

*** Under Standard Option, a treatment plan is required prior to the 9th visit. You must call your local Blue Cross and Blue Shield Plan mental health and substance abuse assistance number on the back of your ID card for Prior Approval. Under Basic Option, you must call your local Blue Cross and Blue Shield Plan mental health and substance abuse telephone number on the back of your ID card prior to receiving any services. All care must have Prior Approval under Basic Option.

This is a summary of the Service Benefit Plan benefits. For a complete description, see the 2008 Service Benefit Plan brochure (RI-71-005).