Blue Cross and Blue Shield Service Benefit Plan For Members Overseas

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 the Blue Cross and Blue Shield Plan in Washington, DC 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. You can use the toll-free numbers when you use the appropriate Telephone Country Codes. If you haven't received your card(s), please notify the Blue Cross and Blue Shield Plan in Washington, DC at 888.999.9862 so they can send your new ID card(s) right away.

Locating A Provider Overseas

You must call the Overseas Assistance Center toll free at 1.800.699.4337 or e-mail the Center at FEPOverseas@worldaccess.com to verify that your selected provider is in our overseas network. The Center can also help you locate a provider if needed.

You can check out providers overseas in your area by using the Find A Provider feature under 2008 Overseas Benefits.

Overseas Benefits At-A-Glance

For professional services provided overseas, we provide benefits at the Preferred benefit level under both Standard and Basic Option, using an Overseas Fee Schedule as our Plan Allowance.

Under Standard Option, you are responsible for any difference between our payment and the amount billed, as well as any amounts applied to the deductible, and coinsurance and copayment amounts. You must also pay for any charges for noncovered services.

Under Basic Option, you pay any difference between our payment and the amount billed, and any coinsurance or copayment amount. You also pay for noncovered services. The requirement to use Preferred network providers does not apply when you receive care outside the US and Puerto Rico.

Facility care you receive overseas is paid at the Preferred benefit level under both options, after you pay the appropriate copayment or coinsurance amount. Standard Option members are also responsible for any amounts applied to the calendar year deductible for certain outpatient facility services.

Most providers are under no obligation to file a claim for our members. In these cases, you will need to file a claim form and pay for the care at the time you receive it. If you need to file a claim, a copy of the Overseas Claim Form is available on this web site.

We will provide translation and currency conversion services for your overseas claims.

Overseas Benefits At-A-Glance
What You Pay *
Preventive Care
Services		Standard Option Benefit		Basic Option Benefit
Adult 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 *		$20 office visit copayment for primary care provider $30 office visit copayment for specialists Nothing for covered preventive screenings billed by your doctor *
Routine physical exams, including a history and risk assessment, chest X-ray, EKG, urinalysis, CBC and metabolic and general health panel tests		$15 for the office visit Nothing for related preventive screening tests *		Nothing for covered charges *
Influenza & Pneumonia Immunizations — See the 2008 Service Benefit Plan brochure for timing information		$15 office visit copayment Nothing for immunizations *		Nothing for covered charges *
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 2008 Service Benefit Plan brochure fee schedule		Benefits paid according to the fee schedule in the 2008 Service Benefit Plan brochure		$20 per exam Benefits limited to 2 exams and cleanings per year Annual X-rays Sealants for children up to age 16
Physician's Care
Services		Standard Option Benefit		Basic Option Benefit
Inpatient services, including surgical and medical care		Subject to $300 calendar year deductible 10% of the Plan Allowance		$100 copayment per surgeon Nothing for other covered services *
Outpatient surgery and related diagnostic tests such as X-rays, laboratory tests and machine diagnostic tests **		Subject to $300 calendar year deductible 10% of the Plan Allowance		$100 copayment per surgeon Nothing for other covered services *
Home and office visits, second surgical opinions, outpatient consultations and medical emergency care		$15 for the visit charge, with no deductible		$20 office visit copayment for primary care provider $30 copayment for specialists
Outpatient physical, occupational and speech therapy		$15 for each visit Physical, occupational and speech therapy: combined maximum of 75 visits per person per year		$20 copayment for primary care provider or other health care professional $30 copayment for specialists Physical, Speech and Occupational therapy: combined maximum of 50 visits per person, per year
Chiropractic Care
Services		Standard Option Benefit		Basic Option Benefit
Spinal manipulations		$15 copayment for each visit Up to 12 spinal manipulations per year per person		$20 copayment for each visit Up to 20 spinal manipulations per year per person
Maternity Care
Services		Standard Option Benefit		Basic Option Benefit
Inpatient hospital care - Precertification is not required		Nothing for covered charges *		$100 copayment for inpatient hospital care
Physician care including delivery and pre-and post-natal care		Nothing for covered charges *		Pre-natal and Post-natal care and delivery: Nothing for covered charges *
Prescription Drugs
Services		Standard Option Benefit		Basic Option Benefit
Prescription Drugs Mail Service Pharmacy — You must have an address with a US zip code and the prescribing physician must be licensed in the US Up to a 90-day supply per prescription or refill		$10 copayment for generic drugs $35 copayment for brand name drugs		Not a benefit
Prescription Drugs Retail Pharmacy Up to a 90-day supply per prescription or refill		Billed charges at the time of purchase, file a claim, then receive 75% of the Plan Allowance as reimbursement		Billed charges at the time of purchase, file a claim, then receive 70% of the Plan Allowance as reimbursement
Hospital/Facility Care
Services		Standard Option Benefit		Basic Option Benefit
Hospital inpatient room and board and other inpatient hospital services - Precertification is not required		Unlimited days $100 per admission copayment		Unlimited days $100 per day up to $500
Hospital/Facility care - outpatient surgery		15% of the Plan Allowance		$40 copayment
Hospital/Facility care - outpatient services including medical emergency care, renal dialysis, radiation therapy and chemotherapy		Subject to $300 calendar year deductible 15% of the Plan Allowance		$40 copayment
Hospital/Facility care - outpatient laboratory and X-ray services **		Subject to $300 calendar year deductible 15% of the Plan Allowance		Nothing for covered services *
Outpatient physical, occupational and speech therapy		$15 for each visit Combined maximum of 75 visits per person per year		$40 copayment Combined maximum of 50 visits per person per year
Accidental Injury
Services		Standard Option Benefit		Basic Option 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 the 2008 Service Benefit Plan brochure.) Includes outpatient medical care, diagnostic tests, and ambulance transportation		Nothing for covered charges *		Emergency Room: $50 copayment Primary Care Provider: $20 copayment Specialist: $30 copayment
Mental Health And Substance Abuse
Services		Standard Option Benefit		Basic Option Benefit
Inpatient Hospital		In full after $100 per admission copayment Unlimited days		$100 per day up to $500 Unlimited days
Outpatient Facility Care		Subject to $300 calendar year deductible 15% of the Plan Allowance		$40 copayment per day per facility
Inpatient Professional Care		Subject to $300 calendar year deductible 10% of the Plan Allowance		Nothing for covered charges *
Outpatient Professional Care		$15 copayment per visit		$20 copayment per visit
Other Services
Services		Standard Option Benefit		Basic Option Benefit
Catastrophic Protection (Please refer to Section 4 of the 2008 brochure for charges applied to this benefit.)		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, copayment and deductible expenses

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.

* You are responsible for the difference between the amount billed and our payment, even when we pay 100% of our Plan Allowance.

** Certain diagnostic cancer tests are paid differently.

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