| Service Benefit Plan |
Standard Option
(PPO providers) |
Basic Option
You must see PPO providers
to receive benefits |
| Calendar Year Deductible |
$250 per person; $500 per family |
No Deductible |
| Physician office visit |
$15 copay |
$20 per office visit for primary physician; $30 per office visit for specialist |
| Preventive care - routine visits |
$15 copay for office visit; additional services no charge |
$20 copay for primary care physician |
| Inpatient hospital care |
$100 per admission copay |
$100 per day up to $500 per admission |
| Inpatient Medical |
After $250 calendar-year deductible, 10% coinsurance for physician services |
Covered in full |
| Inpatient surgical care |
After $250 calendar-year deductible, 10% coinsurance for physician services |
$100 copay per performing surgeon |
| Maternity care |
Covered in full |
Outpatient maternity care paid in full; $100 per admission applies to inpatient facility charges only |
| Well child care |
Covered in full to age 22 |
Covered in full to age 22 |
| Outpatient hospital care, including lab tests, x-rays |
After $250 calendar year deductible, 10% coinsurance (no deductible for surgery) |
$40 copay per day per facility; diagnostic tests (i.e., lab, x-rays) paid in full |
| Outpatient surgery |
After $250 calendar-year deductible, 10% coinsurance for physician services |
$100 copay per surgeon |
Emergency treatment
Outpatient accidental
Other outpatient hospital |
Covered in full within 72 hours
After $250 calendar-year deductible, 10% coinsurance |
$50 copay for hospital emergency room visit
$30 copay for urgent care |
Prescription Drugs
Retail pharmacy
Mail order pharmacy program - up to a 90-day supply |
25% coinsurance
$10 copay for generic
$35 copay for brand-name retail pharmacies |
Level I - $10 copay for generic
Level II - $30 copay for brand-name formulary
Level III - 50% coinsurance for non-formulary brand name ($35 minimum)
No benefit except through Preferred internet providers |
| Dental coverage |
Limited fee schedule |
Preventive services only; $20 copayment per visit |
| Out-of-area coverage |
National and overseas |
National and overseas |
| 24-hour health information service |
Blue Health Connection |
Blue Health Connection |
| Internet Web site |
www.fepblue.org |
www.fepblue.org |
To receive the highest level of benefits to which you are entitled, you must use the Preferred
network providers of the Service Benefit Plan PPO.This is a summary of the features for the year
2006 Blue Cross Blue Shield Service Benefit Plan. Before making a final decision, please
read the plan's federal brochure (RI-71-005). All benefits are subject to the definitions,
limitations and exclusions set forth in the 2006 federal brochure.
