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BE A FRIEND WITH BENEFITS. ENROLL IN BlueValue Direct TODAY.

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STUDY UP.

IT’LL PAY OFF LATER.

Learning these key terms will help you better understand your health plan choices so you can choose the coverage that’s best for you.

Deductible This is the amount you pay before your health plan starts to pay for certain medical bills. It resets January 1st.

Out-of-pocket maximum This protects you against large medical expenses by capping the total amount you could pay in a plan year. (Please note: This amount is different depending on whether you see in-network or out-of-network providers, and copayments do not apply to the out-of-pocket maximum.)

Coinsurance This is a percentage of the total medical bill that you have to pay. For example, some plans have a 20 percent coinsurance charge for physical therapy. So if the total bill is $100, the coinsurance would be $20.

Copayment This is a fixed amount (not a percentage) charged each time you receive a healthcare service. For example, your plan may have a copayment for doctor visits or prescription drugs.

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THESE PROGRAMS WILL HELP YOU SAVE

** Qualifying household income is based on federal poverty levels for 2012.

1 Level One: Gross annual household income at or below 200 percent of the federal poverty level.2 Level Two: Gross annual household income between 201 and 350 percent of the federal poverty level.

You may be eligible to have part of your monthly premium paid through our AccessBlue program. The charts below show how much AccessBlue will pay each month, depending on your household income, if you qualify. Information about AccessBlue, including rates for families, can be found at BCBSRI.com.

Family SizeYou qualify forLEVEL ONE

if your income falls in the range below:1

You qualify forLEVEL TWO

if your income falls in the range below :2

1 $0-$22,340 $22,341-$39,095

LEVEL ONE LEVEL TWOIndividual Individual

$82 $54

Qualifying Household Income**

AccessBlue pays:

Get a Great RateYou may qualify for our preferred rate, which is a discounted rate based on your health status, age, and gender. To apply for our preferred rate, you’ll need to complete the enclosed Direct Pay Medical Underwriting Addendum and return it with your application.

NEW!Diminishing Deductible Reward Yourself for Being Healthy.With our Diminishing Deductible Program, you get a 20 percent deductible reduction following the first year you don’t meet your deductible, and a 40 percent reduction in the second year. If you don’t meet your deductible for three years in a row, your deductible amount is cut in half—50 percent—in year four and stays at that level until you reach your deductible.*

*To be eligible you must have paid your Blue Cross & Blue Shield of Rhode Island Direct Pay premium for six consecutive months of coverage.

If you reach your deductible in any year, your deductible will automatically reset to your original

deductible amount January 1st of the following year. You can work toward reducing your deductible again

for the next year.

YEARLY SAVINGS WHEN YOUR DEDUCTIBLE

IS NOT MET.

1st Year Deductible

2nd Year Deductible

3rd Year Deductible

4th Year Deductible

20%SAVINGS

40%SAVINGS

50%SAVINGS

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HOOK UP WITH A HEALTH PLAN DESIGNED FOR YOU

BlueValue Direct offers benefits that can help you feel and look your best without draining your bank account. With BlueValue Direct, you get: • Our lowest available

premium rates • 100 percent coverage

for preventive medical and dental services (one cleaning and one set of bitewing X-rays per year)

• $4 copayments for most generic drugs

Your Medical Benefits Your Cost

Deductible per calendar year (resets every January 1) – The amount that you must pay each calendar year before BCBSRI begins to pay for certain services.

Individual Deductible $2,500

Family Deductible Not applicable

Out-of-pocket Maximum per calendar year (resets every January 1) – The maximum amount a member pays in a calendar year. IMPORTANT: Once the out-of-pocket maximum (OOP) is met, most benefits are covered in full by BCBSRI.

Individual Out-of-pocket Maximum $7,500

Family Out-of-pocket Maximum Not applicable

Coinsurance – The percentage amount a member pays after the deductible is met.

Coinsurance Liability 50% after deductible

Copayments – The amount a member pays when receiving a service. The copayment does not apply to the deductible or out-of-pocket maximum.

Annual Well Exam Covered at 100% by BCBSRI. There is no charge to the member for an annual well visit.

Primary Care Physician and Specialist First two visits $30 additional visits 50%

coinsurance after deductibleFirst annual Foot and Eye Exam for Diabetics

Urgent Care 50% after deductible

Emergency RoomFirst visit $200

additional visits 50% coinsurance after deductible

Dental Preventive Care

One Dental Cleaning and one set of Bitewing X-rays per year Covered in full

Diagnostic Tests, X-rays, Lab

Diagnostic Radiology Services (high-end radiology services major diagnostic and nuclear medicine including MRI, CT and PET scans)

50% after deductible

Preventive Laboratory Services

Covered in full. There is no charge to the member, i.e. cholesterol test.

Diagnostic Laboratory Services 50% after deductible

Other Covered Services

Inpatient Hospitalization 50% after deductible

Surgery in a Physician’s Office 50% (deductible does not apply)

Physical/Occupational and Speech Therapy 50% after deductible (30 visit limit per specialty)

Prescription Drugs

Tier 1 – Low Cost Generic DrugsTier 2 – Higher Cost Generic and Preferred Brand

Name DrugsTier 3 – Brand Name DrugsTier 4 – Specialty

Tier 1 – $4

$500 deductible applies to Tiers 2, 3, and 4 Once deductible is met your

prescription copays are 50%, 50%, and $200

Incentives

$100 gym membership reimbursement

2013 BlueValue Direct 2500 PLAN BENEFITS*

*Note: This is not a complete list. Check page 6 for infor-mation about other plans for individuals and families, and visit BCBSRI.com for complete plan benefit information.

Out-of-network benefits are available.

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**My Blue Community is a website that enables discussions among individual users. This website is intended solely as a forum for general information and users’ opinions; it does not contain any advice that is intended for medical diagnosis or treatment, and does not substitute for professional medical advice and services. Always seek the advice of your physician or other qualified healthcare provider on any medical condition and before following any information that may appear on My Blue Community.

We can help. Once you enroll in BlueValue Direct, you can get $100 to use toward a gym membership. We’ll also guarantee that you receive the lowest available membership rate at more than 75 gyms in Rhode Island. The actual exercising part, that’s on you!

Learn more about our fitness discount programs as well as other health plan options at BCBSRI.com.

Get off the couch and GO TO THE GYM

Blue365,® a program that offers saving on health and wellness products and services from leading national companies, including Jenny Craig®, Reebok, and many more.

ADDITIONAL RESOURCES HELP YOU SAVE AND MOREOnce you become a Blue Cross member, you’ll have access to resources that can help you save money and take better care of yourself, such as:

Health Center, a website with more than 7,000 articles as well as interactive tools that can help you take the best care of yourself.

Fitness Discount Program, where you’ll get the lowest available membership fees at more than 75 fitness centers in Rhode Island and a 10 percent discount on NordicTrack fitness equipment from Sears.

My Blue Community,SM**an online social network that allows you to connect with more than 30,000 Blue Cross members nationwide and take advantage of expert advice on fitness, nutrition, and more.

Go to BCBSRI.com to learn more about these programs and resources.

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VantageBlue Direct 1000/2000 VantageBlue Direct 1500/3000These plans offer benefits and features that keep you focused on your health, including:

• A $50 incentive for completing an online personal health assessment

• No copayment for the first foot and eye exam for members with diabetes

• $2 prescription drug copayments for certain drugs that treat diabetes, asthma, and chronic obstructive pulmonary disease**

* *You are required to participate in a health management program or choose a doctor who is part of a patient-centered medical home to receive this benefit.

HealthMate Coast-to-Coast® Direct 2500/5000*HealthMate Coast-to-Coast Direct has many traditional features, like predictable copayments and coinsurance for certain services, as well as a Wellness Reward Program designed to reward you for living healthy. You can get back 10 percent of your annual paid premium by simply:

• Choosing a primary care physician for you and your family members

• Completing an online personal health assessment (any dependent 18 years and older)

• Completing certain wellness requirements within the first eight months of joining the program

*A Wellness Health Benefit Plan.

BlueSolutions for HSA Direct 3000/6000 BlueSolutions for HSA Direct 5000/10000These high-deductible health plans are for people who want to take on additional responsibility for their healthcare and feature:

• Some of our lowest available monthly premiums

• Copayments and coinsurance for certain services

• The chance to open a tax-advantaged health savings account (HSA), which you can use to save for current and future medical expenses

All plans offer access to special programs that can help you quit smoking, lose weight, manage your asthma, and more.

For more information about our plans, including complete plan benefit information, their actuarial value, and examples of how they work, please visit BCBSRI.com.

Additional Health Plans. Everyone likes options. That’s why we offer a range of plans for every stage of life.

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Basic Benefits CoverageCalendar Year Maximum $1,000

Oral exams, X-rays, two cleanings per year, fluoride, sealants

100%

Fillings, simple extractions, denture/bridge repairs, root canal therapy, space maintainers, oral surgery

50%

Night guards 50%

Blue Cross Dental Direct Basic

2013 Monthly RatesIndividual $25.97

Enrollee and spouse $51.94

Enrollee and child(ren) $51.68

Family $82.33

No Deductible. No Annual Membership Fee. No Problem.

* Note: This a partial list of benefits and a 12-month waiting period applies to some services.

All plan rates listed above are in effect through December 31, 2013.




Family $126.77

Blue Cross Dental Direct Essential Essential Benefits CoverageCalendar Year Maximum $1,000


100%

Fillings, simple extractions, denture/bridge repair, root canal therapy, space maintainers, oral surgery 80%

Crowns over natural teeth* 50%

Night guards 50%

Blue Cross Dental Direct PlusPlus Benefits CoverageCalendar Year Maximum $1,750


100%

Fillings, simple extractions, denture/bridge repair, root canal therapy, oral surgery

80%

Crowns, bridges, single tooth implants, partial and complete dentures*

50%

Night guards 50%




Family $158.02

WE’VE GOT DENTAL PLANSSMILE.

500 Exchange Street • Providence, RI 02903-2699Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

12/12 DPAY-12525.3165

Just follow these simple steps to enroll:

1. Complete the Health Plan Application.

2. Complete the Direct Pay Medical Underwriting Addendum to apply for our preferred rates.

3. Obtain a Certificate of Creditable Coverage, which you should have received from your most recent health insurance provider.

4. Complete the AccessBlue application, if your household income qualifies (see chart on page 3).

5. Enclose these documents in the provided envelope and send to the address below:

Blue Cross & Blue Shield of Rhode IslandIndividual Sales Department500 Exchange StreetProvidence, RI 02903-2699

Important note: Your application cannot be processed until all the required documents are provided. If you do not have a Certificate of Creditable Coverage, please contact your previous health insurance provider.

LET’S GET STARTED

Looking for More Information?You can always visit BCBSRI.com/BlueValue to find out more about your plan options.

Need Help Choosing Coverage?Call us at (401) 351-BLUE (2583). We’d be happy to help you choose the best plan.

Interested in Dental Coverage?We now offer three comprehensive dental plans. Go to:BCBSRI.com/dentaldirect or call us at:(401) 351-BLUE (2583) to learn more.

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