Blue Cross and Blue Shield Service Benefit Plan.
2008 Standard And Basic Option Benefit Comparison.
This section provides an at-a-glance view of 2008 Standard Option and Basic Option benefit comparison, when you use Network providers.
For a complete explanation of your benefits please see the 2008 Service Benefit Plan brochure. If you do not have a 2008 brochure, you can call your local Blue Cross and Blue Shield Plan at the number on the back of your ID card to request one.
Please Note: The following items are explanations and definitions of language terms and procedures that define benefits mentioned in the Standard and Basic Option benefit comparison information that follows. For an accurate understanding of this Standard and Basic Option Benefits comparison, please read and familiarize yourself with these definitions and procedures.
• Preferred Provider Allowance or PPA is the amount accepted as payment in full by most Preferred professionals and pharmacies.
• Certain deductibles, co-payments 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.
• For mental health and substance abuse 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.
Click on any of the section links that follow or scroll down for a Standard Option and Basic Option benefit comparison when you use Network providers in 2008.
What You Pay When You Use Network Providers.
Preventive Care.
1. Preventive Screenings, Office Visits And Exams For Adults.
For preventive screenings and the related office visit charge, and routine physical examinations for adults you pay:
Under Standard Option PPO Coverage:
You pay the $15 office visit co-payment.
You pay nothing for covered preventive screenings.
Under Basic Option Coverage:
You pay the $20 office visit co-payment for the primary care provider.
You pay the $30 office visit co-payment for specialists.
You pay nothing for covered preventive screenings when they are billed by your doctor.
2. Preventive Screenings, Office Visits And Exams For Children.
For routine physical examinations, routine hearing tests, laboratory tests, immunizations and the related office visit for children under the age of 22 you pay:
Under Standard Option PPO Coverage:
You pay nothing for covered services.
Under Basic Option Coverage:
You pay nothing for covered services.
Physician Care.
1. Physician Inpatient Services And Outpatient Surgery.
For inpatient services, including surgical and medical care, and outpatient surgery you pay:
Under Standard Option PPO Coverage:
You are subject to the $300 calendar year deductible.
You pay the 10% the Preferred Provider Allowance.
Under Basic Option Coverage:
You pay the $100 co-payment per surgeon.
You pay nothing for other covered services.
2. Physician Visits.
For home and office visits, second surgical opinions and consultations you pay:
Under Standard Option PPO Coverage:
You pay $15 for the office visit co-payment.
Under Basic Option Coverage:
You pay the $20 office visit co-payment for the primary care provider.
You pay the $30 office visit co-payment for specialists.
3. Outpatient Physical, Occupational and Speech Therapy.
Under Standard Option PPO Coverage:
You pay the $15 per visit.
Benefits limited to a combined maximum of 75 visits per person per year.
Under Basic Option Coverage:
You pay $20 co-payment per visit for a primary care provider.
You pay $30 co-payment per visit for a specialist.
Benefits are limited to a combined maximum of 50 visits per person per year.
Prescription Drugs.
1. Prescription Drugs Mail Service Pharmacy.
For up to a 90-day supply per prescription or refill you pay:
Under Standard Option PPO coverage:
You pay the $10 co-payment for generic drugs.
You pay the $35 co-payment for brand name drugs.
Under Basic Option Coverage:
This is not a benefit.
2. Prescription Drugs Retail Pharmacy.
Under Standard Option Coverage:
For Standard Option up to a 90-day supply per prescription or refill, you pay 25% of the Preferred Provider Allowance, at the time of purchase (generic and brand name drugs).
Under Basic Option Coverage:
You pay, for up to a 34-day initial supply, the $10 co-payment for generic drugs (for a 90 day supply you pay 3 co-pays), the $30 co-payment for formulary brand name drugs, and 50% coinsurance or $35 minimum for Non-formulary Non-preferred brand name drugs.
Hospital / Facility Care.
1. Hospital / Facility Inpatient.
Precertification is required for hospital inpatient care and you pay:
Under Standard Option PPO Coverage:
You have unlimited days.
You pay the $100 per admission co-payment.
Under Basic Option Coverage:
You have unlimited days.
You pay $100 per day up to $500.
2. Hospital / Facility Outpatient.
For outpatient facility care, excluding physical, occupational, and speech therapy visits you pay:
Under Standard Option PPO Coverage:
You are subject to pay the $300 calendar year deductible.
You pay 15% of the Preferred Provider Allowance.
Under Basic Option Coverage:
You pay the $40 per day, per facility co-payment.
3. Hospital / Facility Outpatient.
For physical, occupational and speech therapy you pay:
Under Standard Option PPO Coverage:
You pay $15 visit co-payment for each visit.
Physical, occupational and speech therapy benefits are limited to a combined maximum of 75 visits per person per year.
Under Basic Option Coverage:
You pay the $40 co-payment for each visit.
Physical, occupational and speech therapy benefits are limited to a combined maximum of 50 visits per person per year.
4. Hospital / Facility Outpatient.
For laboratory and X-ray services:
Under Standard Option PPO Coverage:
You are subject to the $300 calendar year deductible.
You pay 15% of the Preferred Provider Allowance
Under Basic Option Coverage:
You pay nothing.
5. Hospital / Facility Outpatient Surgery.
For outpatient surgery you pay:
Under Standard Option PPO Coverage:
You pay 15% of the Preferred Provider Allowance.
Under Basic Option Coverage:
You pay the $40 co-payment.
Emergency Care.
1. Emergency Care, Accidental Injury.
For emergency room care and ambulance services for accidental injury you pay:
Under Standard Option PPO Coverage:
You pay nothing for covered charges for services rendered within 72 hours of the accident.
Under Basic Option Coverage:
You pay a $50 co-payment for care in a facility, a $20 co-payment for care by a primary care provider, and/or a $30 co-payment for care by specialists.
2. Emergency Care, Medical Emergency.
For emergency room care for the treatment of a medical emergency you pay:
Under Standard Option PPO Coverage:
You are subject to pay the $300 calendar year deductible.
You pay 15% of the Preferred Provider Allowance.
Under Basic Option Coverage:
You pay a $50 co-payment.
For physician care for the treatment of a medical emergency you pay:
Under Standard Option PPO Coverage:
You pay the $15 office visit co-payment.
Under Basic Option Coverage:
You pay a $50 co-payment for care in a facility, a $20 co-payment for care by a primary care provider, and/or a $30 co-payment for care by specialists.
Mental Health And Substance Abuse.
1. Mental Health And Substance Abuse Outpatient Care.
For outpatient professional services you pay:
Under Standard Option PPO Coverage:
You pay the $15 office visit co-payment.
Under Basic Option Coverage:
You pay the $20 office visit co-payment.
Chiropractic Care.
1. Spinal Manipulations.
For spinal manipulations you pay:
Under Standard Option PPO Coverage:
You pay the $15 co-payment for up to 12 spinal manipulations per year.
Under Basic Option Coverage:
You pay the $20 co-payment for up to 20 spinal manipulations per year.
Dental Care.
1. Routine Dental Care.
For routine dental care you pay:
Under Standard Option PPO Coverage:
Your out-of-pocket costs are limited to the Maximum Allowable Charge.
Under Basic Option Coverage:
You pay the $20 office visit co-payment.
Benefits are available for two per year exams and cleanings, annual X-rays, and sealants for children up to age 16.
Other Benefits.
1. Catastrophic Care.
For catastrophic care you pay:
Under Standard Option PPO Coverage:
You pay $4,500 in out-of-pocket coinsurance, co-payment and deductible expenses, before 100% payment level begins.
Under Basic Option Coverage:
You pay $5,000 in out-of-pocket in coinsurance and co-payment expenses, before 100% payment level begins.