Blue Cross and Blue Shield Service Benefit Plan Basic Option

We're delighted to have you as a new member and want to provide you with some important information about your health care benefits. The chart below provides an at-a-glance benefit overview of your coverage, so please take a few moments to review it and familiarize yourself with your new benefits. 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.

Service Benefit Plan Identification Cards

By now, you should have received your Blue Cross and Blue Shield Service Benefit Plan identification card(s). You'll find the most important telephone numbers you need right on the back of your ID card(s), including customer service, precertification (for hospital admissions), prescription drug program and Blue Health Connection telephone numbers. If you haven't received your card(s), please notify your local Blue Cross and Blue Shield Plan so they can send your new ID card(s) right away.

Value-Added Benefits

Blue Health Connection

Blue Health Connection is your resource for around-the-clock health information. Whenever you or a family member has a health care question, registered nurses are available to assess your symptoms and provide health information. You can also get long-term health counseling, listen to a wide range of topics on the audio library or get help locating a Preferred provider after normal business hours. You can access Blue Health Connection online or by calling 1.888.Blue.432.

Davis Vision Care

Davis Vision Care offers savings for eye exams and eyewear to Service Benefit Plan members when you use one of their more than 26,000 participating providers nationwide. There are no claims to file. Just show your Service Benefit Plan ID card to get the discount. You can access information about Vision Care And Eyewear Affinity Discount Program online or call 1.800.551.3337.

Complementary Health Care Benefits

You may purchase a $23 per member yearly membership to gain access to a national network of wellness practitioners and nutritional supplements. You call providers directly to schedule appointments and a physician referral is not required. There are no claim forms for this program, and all charges are handled directly between you and the WholeHealth Networks providers.

For more information, call 1.877.258.7283 from 8:00 am to 8:00 pm Eastern Time, Monday through Friday or go to the WholeHealth Networks web site.

Prescription Drug Discount Program

We also offer a Discount Drug Program that lets you purchase certain prescription drugs not covered by the regular prescription drug benefit at a discount. For more information about the types of drugs covered, please see Prescription Drug Discount Program and the 2008 Service Benefit Plan Brochure.

Preferred Network Providers

Basic Option benefits are only available when you use Preferred network hospitals, physicians, dentists, pharmacies and other health care providers. Preferred network providers accept the Preferred Provider Allowance (PPA) as payment in full. They also take care of claims filing for you. Call your local Blue Cross and Blue Shield Plan to find out if a specific provider is a Preferred network provider or to request a copy of the 2008 Directory of Preferred Network Providers. You can also use our online directory in the Provider Directory feature.

For more information, please read your 2008 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005).

We're glad you chose the Blue Cross and Blue Shield Service Benefit Plan.

We look forward to helping you stay healthy.

Basic Option Benefits At-A-Glance

Under Basic Option, benefits are not available for care that is performed by a Non-preferred provider, except in certain situations such as emergency care.

Benefits for the treatment of mental conditions and substance abuse are not paid differently. However, all care for the treatment of mental conditions and substance abuse must have Prior Approval from your local Blue Cross and Blue Shield Plan. Call the number on the back of your ID card for assistance.

Certain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first) and you use a Preferred Provider.

What You Pay
Preventive Care
Services		Basic Option Network Benefit *
Adult Preventive screenings and related office visit charge, Routine physical exams		$20 office visit copayment for primary care provider $30 office visit copayment for specialists Nothing for covered preventive screenings billed by your doctor
Well Child Care up to age 22, including routine physical examinations, routine hearing tests, laboratory tests, immunizations, and related office visits		Nothing for covered services
Routine Dental Care — See limitations in Section 5(h) of the 2008 Service Benefit Plan brochure		$20 office visit charge 2 exams and cleanings per year Annual X-rays Sealants for children up to age 16
Physician's Care
Services		Basic Option PPO Benefit *
Surgical Care		$100 copayment per surgeon
Home and office visits, second surgical opinions and consultations		$20 office visit charge for primary care provider $30 office visit copayment for specialists
Maternity Care
Services		Basic Option PPO Benefit *
Inpatient Hospital and Physician Care — Precertification is not required		Nothing for professional charges for Pre-natal and Post-natal care and delivery $100 copayment per admission for inpatient hospital care
Prescription Drugs
Services		Basic Option PPO Benefit *
Mail Service Pharmacy		Not a benefit
Retail Pharmacy		Up to an initial 34-day supply $10 copayment for generic drugs $30 copayment for formulary brand name drugs 50% coinsurance ($35 minimum) for non-formulary Non-preferred brand name drugs To Determine Your Prescription Drug Copayment Levels
Hospital/Facility Care
Services		Basic Option PPO Benefit *
Hospital Inpatient — Precertification Required		$100 per day up to $500
Outpatient Facility Care excluding laboratory and X-ray services		$40 per day per facility copayment
Outpatient Facility Care, laboratory and X-ray services		Nothing for covered charges
Outpatient Surgery		$40 copayment
Accidental Injury/Emergency Care
Services		Basic Option PPO Benefit *
Accidental Injury Care — emergency room		$50 copayment
Medical Emergency— emergency room		$50 copayment
Accidental Injury and Medical Emergency - Physician care		$50 copayment
Chiropractic Care
Services		Basic Option PPO Benefit *
Spinal manipulations		Up to 20 spinal manipulations per year $20 copayment
Other Services
Services		Basic Option PPO Benefit *
Catastrophic Benefits		100% payment level begins after you pay $5000 out-of-pocket in coinsurance and copayment expenses

* Under Basic Option, benefits are not available for care that is performed by a Non-preferred provider, except in certain situations such as emergency care.

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