2014...Earn $40 for completing the BHA in 2014! Next: Online Health Coach It’s your own private...
Transcript of 2014...Earn $40 for completing the BHA in 2014! Next: Online Health Coach It’s your own private...
2014
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Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
12014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
While it’s important to choose the right healthcare
coverage with benefits and rates that meet your needs
and those of your family, there is more to health
insurance than benefits and premiums. The Blue Cross
and Blue Shield Service Benefit Plan (Service Benefit
Plan) offers added value in the form of programs and
services that were designed with you and your family’s
health and wellness in mind.
This includes the value of our 24/7 Nurse Line that
provides reliable, personalized advice from
knowledgeable registered nurses.
Our Preferred provider network of hospitals, physicians,
pharmacies and other healthcare professionals is almost
one million strong, so you can find a network provider
near where you live or travel nationwide. Plus, you save
money when you use Preferred providers.
You have peace of mind knowing that the Blue Cross and
Blue Shield Service Benefit Plan ID card is recognized in
the U.S. and around the world.
We also provide a special free assistance center to help
you when you travel overseas.
We reward you for taking charge of your health with
our Wellness Incentive Program. You can earn up to $75
on a health card for taking the Blue Health Assessment
and achieving goals related to a healthy lifestyle.
The value of Blue is all these things and more. Learn
more about what the Service Benefit Plan offers by
reading the information in this book.
You can also learn more about our 2014 benefits
and value-added programs on our website:
www.fepblue.org.
If you would like to talk to someone about your
questions, you can call our Open Season Information
Center at 1-800-411-BLUE beginning October 21
through December 20, 2013.
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32014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary2
WHAT YOU PAYSERVICES 2014 BASIC OPTION NETWORK BENEFIT*
PREVENTIVE CARE — 5(a) and 5(h)
Preventive screenings and related office visit charge; routine physical exams
Nothing for an annual physical and covered preventive screenings
Preventive care for children, up to age 22 Nothing for covered services
Routine dental care $25 copayment per evaluation up to 2 per calendar yearPreventive care only
PHYSICIAN CARE — 5(a) and 5(b)
Surgical care $150 copayment per performing surgeon in an office setting $200 copayment per performing surgeon in another setting
Office visits, consultations and second surgical opinions $25 per visit copayment for primary care provider$35 per visit copayment for specialists
MATERNITY CARE — 5(a)
Inpatient/Outpatient hospital care (Precertification is not required for normal delivery)
$175 copayment per inpatient admission; No out-of-pocket expenses for outpatient covered services
Physician care Physician care including delivery and pre and postnatal care: No out-of-pocket expenses for covered services
HOSPITAL/FACILITY CARE — 5(c)
Inpatient hospital/facility care Precertification is required
$175 per day up to $875 per admission for unlimited days
Outpatient hospital/facility care $100 per day per facility copayment
ACCIDENTAL INJURY/MEDICAL EMERGENCY — 5(d)
Accidental injury and medical emergency $125 copayment for emergency room care$50 copayment for urgent care centerRegular benefits for physician care
CHIROPRACTIC AND OSTEOPATHIC MANIPULATIVE TREATMENT — 5(a)
Manipulative treatment $25 per visit copayment up to 20 manipulations per year
OTHER BENEFITS — 4
Catastrophic benefits 100% payment level begins after you pay $5,500 (Self Only) or $7,000 (Self and Family) out-of-pocket in eligible coinsurance and copayment expenses
Under Basic Option, you must use Preferred providers for
all the medical care you and your family need. Preferred
providers file your claims, and payment will be made to
the provider.
Benefits are only available for care performed by
Non-preferred providers in certain situations, such
as emergency care.
* When you receive care that is performed by a Non-preferred provider, benefits are not available under Basic Option, except in certain situations such as emergency care.
2014 Basic Option Benefits At-A-GlanceCertain cost-sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first). Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for more information. (Brochure sections are identified for your reference.)
Basic Option
DOCTOR’S OFFICE VISIT PREFERRED PROVIDER
Physician’s charge $250
Our allowance $100
We pay Our allowance minus copayment: $75
Your copayment $25
Plus any difference up to the provider’s charge $0
TOTAL YOU PAY $25
Network Providers
EXAMPLE OF YOUR COSTS WHEN YOU USE PREFERRED PROVIDERS
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52014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary4
Standard Option
* When you use Non-preferred hospitals/facilities and professionals, your out-of-pocket expenses are greater and you generally pay any difference between our allowance and the billed amount. Please see Section 10 of the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure.
**Subject to one $350 deductible per member per calendar year; $700 family limit each calendar year.
2014 Standard Option Benefits At-A-GlanceCertain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first). Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for more information. (Brochure sections are identified for your reference.)
More network providers means more choices. Our
nationwide network of almost one million hospitals,
physicians, pharmacies and other healthcare providers
makes it easy to use a Preferred provider. And when
you use a Preferred provider, the provider files the claim.
Payment is made to the provider, and you are only
responsible for any difference between our allowance and
our payment. This is also true for Participating providers.
You can choose to use Non-participating providers, but
your out-of-pocket expenses will be higher than if you
used Preferred or Participating providers.
More Choices
WHAT YOU PAYSERVICES 2014 STANDARD OPTION
PPO BENEFIT2014 STANDARD OPTION NON-PPO BENEFIT*
PREVENTIVE CARE — 5(a) AND 5(h)
Preventive screenings and related office visit charge; routine physical exams
Nothing for an annual physical and covered preventive screenings
35% of the Plan allowance**
Preventive care for children, up to age 22 Nothing for covered services 35% of the Plan allowance**
Routine dental care Your out-of-pocket expenses are limited to the balance after our payment up to the Maximum Allowable Charge
You are responsible for the balance after our payment, up to the billed charge
PHYSICIAN CARE — 5(a) AND 5(b)
Surgical Care 15% of the Plan allowance** 35% of the Plan allowance**
Office visits, consultations and second surgical opinions
$20 per visit copayment for primary care provider
$30 per visit copayment for specialists
35% of the Plan allowance**
MATERNITY CARE — 5(a)
Inpatient/Outpatient hospital care (Precertification is not required for normal delivery)
No out-of-pocket expenses for covered services
$350 per admission copayment plus 35% of the Plan allowance
Physician Care No out-of-pocket expenses for covered services
35% of the Plan allowance**
HOSPITAL/FACILITY CARE — 5(c)
Inpatient hospital/facility care Precertification is required
$250 per admission copayment for unlimited days
$350 per admission copayment plus 35% of the Plan allowance
Outpatient hospital/facility care 15% of the Plan allowance** 35% of the Plan allowance**
ACCIDENTAL INJURY/MEDICAL EMERGENCY — 5(d)
Accidental injury within 72 hours of accident Nothing for covered services Nothing for covered services; you pay any difference between our allowance and billed charges
Medical emergency/facility care Emergency room: 15% of the Plan allowance**
Urgent care center: $40 copayment
Emergency room: 15% of the Plan allowance**
Urgent care center: 35% of the Plan allowance**
Medical emergency/professional care $20 per visit copayment for primary care provider
$30 per visit copayment for specialists
35% of the Plan allowance**
OTHER BENEFITS — 4
Catastrophic Benefits 100% payment level begins after you pay $5,000 (Self Only) or $6,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses
100% payment level begins after you pay $7,000 (Self Only) and $8,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses
DIAGNOSTIC TEST (SUCH AS AN X-RAY OR BLOOD WORK)
PREFERRED PROVIDER
PARTICIPATING PROVIDER
NON-PARTICIPATING PROVIDER
Physician’s charge $250 $250 $250
Plan allowance $100 $100 $100
We pay 85% of the Plan allowance or $85 65% of the Plan allowance or $65 65% of the Plan allowance or $65
Your coinsurance 15% of the Plan allowance or $15 35% of the Plan allowance or $35 35% of the Plan allowance or $35
Plus any difference up to the provider’s charge $0 $0 $150
YOUR TOTAL ESTIMATED PAYMENT $15 $35 $185
EXAMPLE OF YOUR SAVINGS WHEN YOU USE PREFERRED PROVIDERS
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6 72014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
New Health Tools on MyBlue®
All-New Health Tools on MyBlue WebsiteMyBlue features new, mobile Health Tools and
resources—the latest health and wellness information
within easy reach from your computer, smartphone
or tablet. It’s everything you already love about
Blue—but better!
Start Here: Blue Health AssessmentWhat you don’t know can hurt you. Take the redesigned
Blue Health Assessment (BHA) to address health risks
before they become issues. Answer simple questions and
in just 10 minutes receive a clear, concise, personalized
approach to a healthier you. You can even take the BHA
multiple times throughout the year to update your plan
and see your progress. Earn $40 for completing the BHA
in 2014!
Next: Online Health CoachIt’s your own private cheering section! When you work
with the all-new Online Health Coach on your path
to better health, you’ll get suggestions for realistic,
personalized activities to stay on track. Start by taking
the BHA, then earn rewards—up to $35—when you
achieve your exercise, stress management, emotional
health, weight loss and nutrition goals. Get ideas and
encouragement for managing your chronic conditions,
like diabetes, asthma and others.
Anytime: Nurse Line Call, chat online or email the Nurse Line for
reliable health information, anytime day or night.
Visit www.fepblue.org or call 1-888-258-3432 to
get reliable health information from knowledgeable,
registered nurses.
Anytime: Personal Health Record Your all-new Personal Health Record (PHR) gives you
easy access to your health information, making it simple
for you to keep track of your medical history,
appointments and lab results. There’s no need to worry
that you’ve forgotten important health details—your PHR
has you covered. When you complete the BHA and work
with the Online Health Coach, this information is fed to
your PHR. Plus, wherever your smartphone goes, your
PHR goes, too!
Anytime: Benefits Statements Let your Benefits Statements be your benefits assistant!
Find ways to save and see a snapshot of your claims and
your benefits in annual or quarterly time periods—anytime
you need answers, not just when you’re close to your filing
cabinet. Access your statements on your computer,
smartphone or tablet—from home, the doctor’s office or
pharmacy. Starting February 2014, you can contact
1-888-258-3432 to request paper statements.
Anytime: Online Symptom Checker Use the Online Symptom Checker to receive possible
reasons for your symptoms*—from your computer,
smartphone or tablet. If you have questions while using
the Online Symptom Checker, you can chat online with
the Nurse Line, too!
*Seek immediate medical attention for life-threatening health issues.
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The Blue Cross and Blue Shield Service Benefit Plan is
introducing new Health Tools powered by WebMD, one
of the most trusted healthcare brands in the U.S. Starting
January 1, 2014, you’ll have new and improved wellness
tools and resources available on the MyBlue website.
Imagine simple, private and smart tools and resources that
you can securely access anytime, anywhere—on your
computer, tablet or smartphone:
• Share your test results with a new doctor—in her office.
• Tell the pharmacist the dosage of your partner’s prescription—at the pharmacy.
• Access activities, challenges and trackers to help you achieve your health goals—from the gym, your home or the office.
• Chat online about your baby’s fever and sleep patterns with a nurse—on a Sunday morning.
• Organize and clear your filing cabinet of all your family’s health claims—even at midnight.
• Enter your symptoms and receive possible reasons for why you have that nagging cough—from the comfort of your home.
Our tools offer support that’s motivational and realistic to
help you where and when you need it.
Your data is secure. The Service Benefit Plan and WebMD
take the safety and security of your health information
very seriously. All of our systems operate in accordance
with federal privacy laws, and we take every effort to
protect your privacy when you use any of our online tools
and resources.
New year, new start! Blue has you covered!
92014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
Diabetes Management Incentive ProgramThe Diabetes Management Incentive Program
provides critical education if you have diabetes, assists
in improving your blood sugar control and helps to
manage or slow the progression of complications
related to diabetes.
To be eligible for this program, you must be 18 years
of age or older and complete the BHA and indicate
you have diabetes. This program is limited to two adult
members if you have family coverage.
You will receive credit on your MyBlue Wellness Card
when you complete specific activities. Please note: Once
you earn the maximum of $75 under the Diabetes
Management Incentive Program, you will not earn
additional credits to your MyBlue Wellness Card for
completing additional activities under this incentive.
Tobacco Cessation Incentive ProgramIf you are ready to stop using tobacco, we have the
support you need for success. Take the BHA and indicate
that you use tobacco and then use the Online Health
Coach to select the tobacco cessation goal and create a
plan to quit. After you complete these steps, you’ll be
eligible to receive tobacco cessation products for free.
Both prescription and over-the-counter (OTC) tobacco
cessation products obtained from a Preferred retail
pharmacy are included in this program for Standard
Option and Basic Option members age 18 or older.
When you use a Preferred retail pharmacy to get certain
prescription tobacco cessation medications, we will
waive the cost share. In addition, we will provide benefits
in full for specific OTC tobacco cessation medications
when you purchase the medications at a Preferred retail
pharmacy and have a doctor’s prescription.
EARN WHEN YOU
$20Have A1c tests performed by a covered provider, maximum of two per year, $10 each
$10 Report A1c levels, maximum of two per year, $5 each
$40Purchase diabetic glucose test strips through our Retail or Mail Service Pharmacy, maximum of four per year, $10 each
$10 Have a diabetic foot exam from a covered provider, maximum of one per year, $10
$20
Complete one of the following activities:• $20 for enrolling in a diabetic disease
management program, one per year, OR
• $20 for a diabetic education visit to a covered provider, one per year, OR
• $5 each for completing web-based diabetes education quizzes on our website, up to four per year
$75 Total Maximum Credit
MyBlue® Wellness CardThe MyBlue Wellness Card is a pre-paid card we use to
reward our members for taking charge of their health.
The card is available to members who complete specific
activities to improve their health and may be used to pay
for qualified medical expenses.
Please note: For members who received a MyBlue
Wellness Card in 2011-2013, any new credits will be
applied to your existing card.
Wellness Incentive Program: Blue Health Assessment (BHA) and Online Health Coach Complete the BHA for 2014 to receive $40 on your
MyBlue Wellness Card. Members must be 18 years of age
or older to be eligible for the incentive. Family contracts
are eligible to receive two $40 cards when two adult
members complete the BHA.
After you take the BHA, if you need help reaching your
health and wellness goals or maybe just a push in the
right direction, the Online Health Coach is there for you.
You can set and work toward any number of goals that
you choose in a variety of areas.
You may also receive up to an additional $35 on your
MyBlue Wellness Card for achieving goals related to
a healthy lifestyle in the areas of exercise, nutrition,
stress, weight management and emotional health.
After completing the BHA, you may choose to complete
goals in any of these five areas, up to a maximum
of three goals per calendar year to earn a reward.
When you achieve your first goal, you will receive $15
on your card. For the second and third goals, you will
receive $10 on your card for each one. All three goals
must be completed during the calendar year to earn
the reward.
Extra Motivation!Take steps toward better health and earn up to $75*
Up to two adult-covered family members can each earn up to $75 after completing all four steps.
* Incentive rewards are added to your MyBlue Wellness Card to pay for
qualified medical expenses.
** Goals must be started and completed within the calendar year.
Reward Programs
More benefits. More peace of mind.
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EARN WHEN YOU
$40 Complete the Blue Health Assessment
$15 Achieve your first goal with the Online Health Coach**
$10 Achieve your second goal with the Online Health Coach**
$10 Achieve your third goal with the Online Health Coach**
10 112014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
Blue ExtrasHealth Club Membership You pay a $25 initiation fee and $25 monthly for
unlimited visits to over 8,000 fitness facilities nationwide.
You are not limited to a specific facility.
For more information, go to www.fepblue.org.
Other Programs• WalkingWorks® is a good start for any exercise routine
with a free pedometer and online walking guide.
Visit www.fepblue.org for more information.
• Blue365® offers access to information, discounts and
savings that make it easier and more affordable to
make healthy choices. For more information, go to
www.fepblue.org.
• Our Vision Care Affinity Program provides savings on
routine eye exams, frames, lenses, contact lenses and
laser vision correction when you use a network
provider. Visit www.fepblue.org for additional
information about this program or call 1-800-551-3337.
• Local Care Management Programs, offered by local
Blue Cross and Blue Shield Plans, provide patient
education and support for select diagnoses. Call
your local Blue Cross and Blue Shield Plan for more
information about these programs.
MyBlue Customer eServiceMyBlue Customer eService is like having your own
personal customer service representative when you
need help managing your enrollment. You can view
your Explanation of Benefits online, request duplicate ID
cards, change your address, add children after a birth or
adoption and let us know about a marriage or divorce.
Visit www.fepblue.org for more information.
Online Explanation of BenefitsYou can decide to go paperless and access your
Explanation of Benefits (EOB) online through MyBlue
Customer eService. You can see and print information
about claims processed for you and your family.
It is easy to opt in to paperless EOBs. Sign on to
www.fepblue.org/myblue.
Finding CareNational Doctor and Hospital Finder Our directory of Preferred providers gives you
the control to choose your healthcare providers
while saving you money on medical costs
through our negotiated discounted rates.
Visit www.fepblue.org/provider for details.
With the Blue Finder smartphone app, finding a
doctor or hospital has never been easier! One tap
with the Blue Finder app connects you to the closest
provider, hospital, or urgent care center. You can dial
a provider’s phone number and use the interactive GPS
map and driving directions to get to your selected
location. Text and email options allow you to share
and save your results.
Blue Distinction Centers®The hospital you select can have a direct impact on
the care you receive and your procedure results, but
finding the right hospital can sometimes be challenging.
You deserve peace of mind when making important
healthcare decisions with your doctor. That’s why we
developed the Blue Distinction Centers recognition
program to identify hospitals with proven expertise in
delivering specialty care.
Blue Distinction Centers and Blue Distinction Centers+
are available nationwide no matter where you work,
live or travel—and finding one is easy. Visit the Blue
Distinction Center Finder at www.bcbs.com/bdcfinder.
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132014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary12
Mail Service Pharmacy Program—Standard Option Only The Mail Service Pharmacy Program for Standard
Option is an easy way to get medications you take
regularly for a chronic condition with the convenience
of home delivery.
If you have any questions about the Mail Service
Pharmacy Program or want to talk to a pharmacist about
your medications, you can call anytime. This benefit is
not available under Basic Option.
Using the Mail Service Pharmacy is easy.1. Ask your physician to prescribe up to a 90-day supply
(minimum 21-day supply) of your medication plus
refills for up to one year.
2. Send your original prescription, the appropriate
copayment amount and your completed mail service
order form to the address on the form. You can
request order forms on www.fepblue.org or by
calling 1-800-262-7890. You can also ask your doctor
to order a prescription for you by calling this number
and pressing Option 3.
3. All medications and instructions are sent via U.S.
Postal Service, except medications that require
overnight shipping. You should receive your
prescription within two weeks from the time
you mail in your order.
4. You can order refills by returning the refill slip by mail,
ordering online at www.fepblue.org under Pharmacy
to request the refill or by calling 1-877-337-3455
24 hours a day, seven days a week.
Retail Pharmacy Program— Both OptionsBasic Option members must use a Preferred retail
pharmacy to obtain medications. Standard Option
members can use any Preferred or Non-preferred retail
pharmacy. However, if you use a Non-preferred
pharmacy, you pay the full cost of the drug and then file
a claim for reimbursement. Your cost share is 45% of the
Average Wholesale Price, plus any difference between
our allowance and the billed amount.
Just show your Blue Cross and Blue Shield Service
Benefit Plan ID card at a Preferred pharmacy. You pay
only the appropriate copayment or coinsurance amount.
If you have any questions about the Preferred Retail
Pharmacy Program, you can call 1-800-624-5060 to
talk to a member service representative.
We have over 60,000 Preferred network retail
pharmacies nationwide. You can locate a Preferred retail
pharmacy near you by calling 1-800-624-5060 or by
visiting the Pharmacy section on www.fepblue.org.
Pharmacy Programs
WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS
BENEFIT 2014 STANDARD OPTION COVERAGE 2014 BASIC OPTION COVERAGE
PRESCRIPTION DRUGS
Mail Service Pharmacy Tier 1 (generics)*: $15 copaymentTier 2 (Preferred brand name): $80 copaymentTier 3 (Non-preferred brand name): $105 copaymentCovers 22-90-day supply
Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs
Not a benefit
Preferred Retail Pharmacy Program
Tier 1 (generics)*: 20% coinsuranceTier 2 (Preferred brand name): 30% coinsuranceTier 3 (Non-preferred brand name): 45% coinsurance
Covers up to a 90-day supply
Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs when you use a Preferred PharmacyTier 4 (Preferred specialty drugs): 30% coinsurance
Tier 5 (Non-preferred specialty drugs): 30% coinsurance
Tier 4 and 5 speciality drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.
Tier 1 (generics): $10 copaymentTier 2 (Preferred brand name): $45 copaymentTier 3 (Non-preferred brand name): 50% coinsurance with a $55 minimum
Covers 30-day supply, up to 90-day supply for additional copaymentsTier 4 (Preferred specialty drugs): $60 copayment (30-day supply)
Tier 5 (Non-preferred specialty drugs): $80 copayment (30-day supply)
Tier 4 and 5 speciality drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.
Specialty Pharmacy Program Tier 4 (Preferred specialty drugs): $35 copayment (30-day supply); $95 copayment (90-day supply)
Tier 5 (Non-preferred specialty drugs): $55 copayment (30-day supply); $155 copayment (90-day supply)
90-day supply can only be obtained after 3rd fill
Tier 4 (Preferred specialty drugs): $50 copayment (30-day supply); $140 copayment (90-day supply)
Tier 5 (Non-preferred specialty drugs): $70 copayment (30-day supply); $195 copayment (90-day supply)
90-day supply can only be obtained after 3rd fill
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SCertain prescription drugs require prior approval.*Benefits for generic prescription drugs are different if you have Medicare Part B as your primary coverage.
152014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
When You Live or Travel OverseasIf you need medical care outside the United States,
you can be assured that your Blue Cross and Blue Shield
Service Benefit Plan ID card entitles you to world class
service. Your Service Benefit Plan coverage protects
you around the world.
Worldwide Assistance CenterThe Worldwide Assistance Center offers help when
you are traveling outside the U.S., Puerto Rico and the
U.S. Virgin Islands, 24 hours a day, seven days a week.
Bilingual operators are also available to help you.
The Center can help you locate a provider. You can
call the Center collect at 1-804-673-1678 or email
[email protected] for help.
How Benefits Work OverseasInpatient Hospital Care: Under both options, benefits
are paid at the Preferred level. Precertification is not
required for hospital admissions outside the U.S.
Outpatient Hospital Care: Benefits under Standard
and Basic Option are paid at the Preferred level.
Physician Care: Benefits for physician care and
care by other covered professional providers
performed outside the U.S. are paid at the Preferred
level using an Overseas Fee Schedule or a provider
negotiated amount.
Prescription Drugs: Drugs that require a prescription
overseas may differ from those that require a
prescription in the U.S. Drugs purchased outside
the U.S. must be an equivalent product that by U.S.
federal law that requires a prescription for purchase in
the U.S., or there must be clinical evidence that
prescribing the drug is consistent with the standard of
medical practice in that country.
• Standard Option members can order prescription drugs
through the Mail Service Pharmacy Program if your
address has a U.S. zip code and the prescribing
physician is licensed in the U.S.
• For both Standard and Basic Option, if you purchase
a prescription drug at a local pharmacy outside
the U.S., you pay for the drug and then file a claim
for reimbursement. Payment will be made at the
Preferred level.
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Filing ClaimsMembers can mail claims to us, fax them to us or submit
claims for medical care performed and prescription
drugs purchased overseas through the MyBlue portal
on www.fepblue.org. For information about mailing
and faxing claims to us, see Section 5(i) in the 2014
Blue Cross and Blue Shield Service Benefit Plan brochure.
To submit your claims electronically:
1. Go to the MyBlue Portal and log in if you have
already registered. If not, you will have to set up
a MyBlue account.
2. On the MyBlue Welcome page, under Overseas,
select Submit an Overseas claim online.
3. Follow the step-by-step directions to submit the
claim, including completing the fillable claim form
PDF, scanning your bills and uploading the files.
You can also take advantage of bank wire payment
and get your payment faster for overseas medical claims.
You can select to have the wire payment in a foreign
currency or U.S. dollars. Just complete Section 6 of
the online overseas medical claim form to select wire
payments and the currency you prefer.
Payments by check for covered drugs and supplies
you purchase from pharmacies outside the U.S.,
Puerto Rico and the U.S. Virgin Islands can only be
made in U.S. dollars.
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Please note that for overseas countries with laws restricting the importation of prescription drugs from any other country, we are unable to ship drugs from our Mail Service Pharmacy Program to Standard Option members living overseas or from our Specialty Pharmacy Program to Standard or Basic Option members living overseas, even when a valid APO or FPO address is available. You may continue to obtain your prescription drugs from a local overseas pharmacy and submit a claim to us for reimbursement by faxing it to 001-480-614-7674 or filing it via our website at www.fepblue.org/myblue.
16 172014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
2014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan ComparisonCertain deductibles, copayments and coinsurance amounts do not apply if Medicare is your primary coverage for medical services (it pays first).
WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS
BENEFIT 2014 STANDARD OPTION COVERAGE* 2014 BASIC OPTION COVERAGE**
PHYSICIAN CARE
Office visits and outpatient consultations
$20 per visit copayment for primary care provider$30 per visit copayment for specialists
$25 per visit copayment for primary care provider$35 per visit copayment for specialists
Routine exams and other preventive care services
Nothing for covered services Nothing for covered services
Surgical services Prior approval is required for certain surgical services
15% of the Plan allowanceSubject to calendar year deductible
$150 copayment per performing surgeon in an office setting$200 copayment per performing surgeon in another setting
HOSPITAL/FACILITY CARE
Hospital inpatientPrecertification is required
$250 per admission copayment for unlimited days $175 per day up to $875 per admission for unlimited days
Outpatient hospital/facility care 15% of the Plan allowanceSubject to calendar year deductible
$100 per day facility copayment
PRESCRIPTION DRUGSCertain prescription drugs require prior approval.
Mail Service Pharmacy Program Tier 1 (generics)***: $15 copaymentTier 2 (Preferred brand name): $80 copaymentTier 3 (Non-preferred brand name): $105 copaymentCovers 22-90 day supplyNothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs
Not a benefit
Preferred Retail Pharmacy Program Tier 1 (generics)***: 20% coinsuranceTier 2 (Preferred brand name): 30% coinsuranceTier 3 (Non-preferred brand name): 45% coinsuranceCovers up to a 90-day supplyNothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs when you use a Preferred PharmacyTier 4 (Preferred specialty drugs): 30% coinsuranceTier 5 (Non-preferred specialty drugs): 30% coinsuranceTier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.
Tier 1 (generics): $10 copaymentTier 2 (Preferred brand name): $45 copaymentTier 3 (Non-preferred brand name): 50% coinsurance with a $55 minimumCovers 30-day supply, up to 90-day supply for additional copaymentsTier 4 (Preferred specialty drugs): $60 copayment (30-day supply)Tier 5 (Non-preferred specialty drugs): $80 copayment (30-day supply)Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.
Specialty Pharmacy Program Tier 4 (Preferred specialty drugs): $35 copayment (30-day supply); $95 copayment (90-day supply)Tier 5 (Non-preferred specialty drugs): $55 copayment (30-day supply); $155 copayment (90-day supply)90-day supply can only be obtained after 3rd fill
Tier 4 (Preferred specialty drugs): $50 copayment (30-day supply); $140 copayment (90-day supply)Tier 5 (Non-preferred specialty drugs): $70 copayment (30-day supply); $195 copayment (90-day supply)90-day supply can only be obtained after 3rd fill
* When you use Non-preferred hospitals/facilities and professionals, your out-of-pocket expenses are greater. Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for details.
** Basic Option does not generally provide benefits for services rendered by Non-preferred providers.
*** Benefits for generic prescription drugs are different if you have Medicare Part B as your primary coverage.
Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for complete details.
WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS
BENEFIT 2014 STANDARD OPTION COVERAGE* 2014 BASIC OPTION COVERAGE**
LAB, X-RAY AND OTHER DIAGNOSTIC SERVICES
Diagnostic test (X-ray, blood work)Imaging (CT/PET scans, MRIs)
15% of the Plan allowanceSubject to calendar year deductible
$0 copayment for laboratory tests, pathology services and EKGs$40 copayment for diagnostic tests such as EEGs, ultrasounds and X-rays$100 copayment for bone density tests, sleep studies, CT scans, MRIs, PET scans, angiography, genetic testing and nuclear medicine at a professional provider; $150 copayment at a hospital
EMERGENCY CARE
Accidental injury
Medical emergency
Accidental injury: Nothing for outpatient, hospital and physician services within 72 hoursMedical emergency: Regular benefits for physician and hospital care (Subject to calendar year deductible); $40 copayment for urgent care center
Accidental injury and medical emergency:$125 copayment for emergency room care$50 copayment for urgent care centerRegular benefits for physician care
MATERNITY CARE
Inpatient/Outpatient hospital care Precertification is not required for normal deliveryPhysician care
Inpatient/Outpatient hospital care: No out-of-pocket expenses for covered services
Physician care including delivery and pre and postnatal care: No out-of-pocket expenses for covered services
Inpatient/Outpatient hospital care: $175 copayment per inpatient admission; No out-of-pocket expenses for outpatient covered servicesPhysician care including delivery and pre and postnatal care: No out-of-pocket expenses for covered services
DENTAL CARE
Routine dental care Up to age 13: The difference between $12 and the Maximum Allowable Charge (MAC)Age 13 and over: The difference between $8 and the MAC
$25 copayment per evaluation up to 2 per calendar yearPreventive care only
CHIROPRACTIC/OSTEOPATHIC MANIPULATIVE TREATMENT
Manipulative treatment $20 per visit copayment up to 12 manipulations per year $25 per visit copayment up to 20 manipulations per year
OTHER BENEFITS
Catastrophic benefits 100% payment level begins after you pay $5,000 (Self Only) or $6,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses with Preferred providers
100% payment level begins after you pay $5,500 (Self Only) or $7,000 (Self and Family) out-of-pocket in eligible coinsurance and copayment expenses
* When you use Non-preferred hospital/facilities and professionals, your out-of-pocket expenses are greater. Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for details.** Basic Option does not generally provide benefits for services rendered by Non-preferred providers.
The 2014 Blue Cross and Blue Shield Service Benefit Plan brochure is your best resource for detailed information about
the benefits and services most important to you. Please do not rely solely on the summary of benefits in this pamphlet.
You can access and download a copy of our 2014 brochure at www.fepblue.org.
As You Make Your Open Season Choices
Open Season DatesThe 2013 Open Season for health insurance changes runs from Monday, November 11, 2013, through Monday, December 9, 2013.
Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, refer to the Guide to Federal Benefits for that category or contact the agency that maintains your health benefits enrollment. Career non-law enforcement employees may also refer to the Guide to Federal Benefits for United States Postal Service Employees, RI 70-2, to determine their rates.
Different rates apply and a special guide is published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-21N). For additional assistance, Postal Service employees can call the Human Resources Shared Service Center at 1-877-477-3273 and select Option 5. Postal rates do not apply to non-career postal employees, postal retirees or associate members of any postal employee organization who are non-career postal employees. Refer to the applicable Guide to Federal Benefits.
This is a summary of the features for 2014 Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005). All benefits are subject to the definitions, limitations and exclusions set forth in the 2014 brochure.
Please visit our web site www.fepblue.org for more information about your Service Benefit Plan coverage.
AskBlue for Federal Employees
Do you ever wonder if your current option is still the right one for you
and your family? AskBlue is designed to help you make this type of
decision about your health insurance coverage. It is a personal guide
that is simple and provides straightforward answers to your health
insurance choice questions. Visit askblue.fepblue.org.
TYPE OF ENROLLMENT BIWEEKLY MONTHLY BIWEEKLY
Standard Option Self Only (104) $87.82 $190.28 $65.96
Standard Option Family (105) $204.98 $444.12 $156.36
Basic Option Self Only (111) $60.96 $132.09 $40.24
Basic Option Family (112) $142.75 $309.30 $94.22
2014 Premiums and Rates
NON-POSTAL PREMIUM2014 Premiums—Your Share POSTAL PREMIUM
Category 1 Category 2
$79.62
$186.75
$53.04
$124.20