1. Healthcare

VALUE
OF BLUE
BASIC
OPTION
STANDARD
OPTION
HEALTH
TOOLS
REWARD
PROGRAMS
BLUE
EXTRAS
PHARMACY
PROGRAMS
2015 STANDARD &
BASIC OPTION
BLUE CROSS AND BLUE SHIELD SERVICE BENEFIT PLAN SUMMARY
WORLDWIDE
COVERAGE
VALUE
OF BLUE
VALUE OF BLUE
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 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.
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
$85 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 2015 benefits and
value-added programs on our website:
www.fepblue.org.
If you have questions, you can call our Open Season
Information Center at 1-800-411-BLUE (2583)
beginning October 20 through December 19, 2014.
You have peace of mind knowing that the Service
Benefit Plan ID card is recognized in the U.S. and
around the world.
2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
11
BASIC OPTION
2015 Basic Option Benefits at a Glance
Certain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first).
Please see the 2015 Service Benefit Plan brochure for more information. Brochure sections are identified for your reference.
SERVICES
Under Basic Option, you use Preferred providers for all
the medical care you and your family need. Preferred
providers file your claims, and payment will be made
directly to the provider.
Benefits are only available for care performed by
Non-preferred providers in certain situations, such as
emergency care.
BASIC
OPTION
WHAT YOU PAY
Network Providers
2015 BASIC OPTION NETWORK BENEFIT*
PREVENTIVE CARE — 5(a) and 5(g)
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 year
Preventive care only
EXAMPLE OF YOUR SAVINGS WHEN YOU USE PREFERRED PROVIDERS
PHYSICIAN CARE — 5(a) and 5(b)
DOCTOR’S OFFICE VISIT
PREFERRED PHYSICIAN
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
Surgical care
$150 copayment per performing surgeon in an office visit 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
$35 copayment for urgent care center
Regular 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
*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.
2
2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
3
2015 Standard Option Benefits at a Glance
STANDARD OPTION
Certain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first). Please see the 2015
Service Benefit Plan brochure for more information. Brochure sections are identified for your reference.
WHAT YOU PAY
SERVICES
More Choices
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 use Preferred
or Participating providers.
2015 STANDARD OPTION
USING NON-PREFERRED PROVIDERS*
PREVENTIVE CARE — 5(a) and 5(g)
Preventive screenings and related office visit Nothing for an annual physical and covered
charge; routine physical exams
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
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
35% of the Plan allowance**
STANDARD
OPTION
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 directly to the provider, and
you are only responsible for any difference between our
2015 STANDARD OPTION
USING PREFERRED PROVIDERS
PHYSICIAN CARE — 5(a) and 5(b)
EXAMPLE OF YOUR SAVINGS WHEN YOU USE PREFERRED PROVIDERS*
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
$30 per visit copayment for specialists
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**
(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**
HOSPITAL/FACILITY CARE — 5(c)
*This example assumes the calendar year deductible has been met.
$35
$185
Inpatient hospital/facility care
ACCIDENTAL INJURY/MEDICAL EMERGENCY — 5(d)
Accidental injury within 72 hours of accident
Nothing for covered services
Medical emergency/facility care
Emergency room: 15% of the Plan allowance** Emergency room: 15% of the Plan allowance**
Medical emergency/professional care
Nothing for covered services; you pay
any difference between our allowance
and billed charges
Urgent care center: $30 copayment
Urgent care center: 35% of the Plan
allowance**
$20 per visit copayment for primary care
provider
35% of the Plan allowance**
$30 per visit copayment for specialists
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
* 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 1 of the 2015 Service Benefit Plan brochure.
** Subject to one $350 deductible per member per calendar year; $700 family limit each calendar year.
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2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
5
HEALTH TOOLS
ON MYBLUE
Health Tools on MyBlue website
MyBlue now features 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!
®
New year, new start! Blue has you covered!
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 the doctor’s office.
• Keep track of your prescriptions.
• Access activities and trackers to help
you achieve your health goals—from the gym,
your home or the office.
• Chat, call or email about your baby’s fever and sleep
patterns with a nurse—on a Sunday morning.
• Review your well-organized, comprehensive medical
history—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
about the challenges real people face.
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 the
tools and resources.
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Start Here: Blue Health Assessment
What you don’t know can hurt you. Take the
redesigned 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 $50 the first
time you complete the BHA in 2015!
Next: Online Health Coach
It’s your own private cheering section! When you
work with the Online Health Coach on your path
to better health, you’ll get suggestions for realistic,
personalized activities to help you 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
using the Online Health Coach. Also, get ideas and
encouragement for managing your chronic conditions,
like diabetes, asthma and others.
Anytime: Benefits Statements
Let your Benefits Statements be your benefits
assistant! Find ways to save and see a snapshot of
your claims and 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. Print
your statements from home or you can contact
1-888-258-3432 to request paper statements.
HEALTH
TOOLS
The Blue Cross and Blue Shield Service Benefit Plan is
continuing to offer Health Tools, powered by WebMD,
one of the most trusted healthcare brands in the U.S. In
2015, you’ll have new and improved wellness tools and
resources, available on the MyBlue website. We’re even
giving you more of an incentive to complete our Health
Tools in 2015---$50 just for completing the Blue Health
Assessment (BHA)!
Anytime: Nurse Line
Call, chat online or email the Nurse Line for reliable
health information, anytime day or night. Visit
www.fepblue.org/myblue or call 1-888-258-3432
to get reliable health information from knowledgeable,
registered nurses.
Anytime: Personal Health Record
Anytime: Online Symptom Checker
Your 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!
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.
2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
7
REWARD PROGRAMS
MyBlue® Wellness Card
The MyBlue Wellness Card is a debit 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.
MORE BENEFITS.
MORE PEACE OF MIND.
Please note: If you have a MyBlue Wellness Card,
keep your card until it expires. Any new credits will be
applied to your existing card.
Wellness Incentive Program:
Blue Health Assessment (BHA)
and Online Health Coach
Take steps toward better health and earn up to $85*
WHEN YOU
Complete the BHA in 2015 to receive $50 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 $50
cards when two adult members complete the BHA.
$50
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**
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.
$10
Achieve your third goal with the Online
Health Coach**
Up to two covered adult family members can each
earn up to $85 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.
The 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 in 2015.
EARN UP TO $75 WHEN YOU DO ANY
COMBINATION OF THE FOLLOWING ACTIVITIES
Have A1c tests performed by a covered provider, maximum of
two per year, $10 each
Report A1c levels, maximum of two per year, $5 each
Purchase diabetic glucose test strips through our Retail or
Mail Service Pharmacy, maximum of four per year, $10 each
Have a diabetic foot exam from a covered provider, maximum
of one per year, $10
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
programs on our website, up to four per year
Tobacco Cessation
Incentive Program
REWARD
PROGRAMS
EARN
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.
8
Extra Motivation!
Diabetes Management
Incentive Program
If 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 pharmacy to get certain prescription
tobacco cessation drugs, we will waive the cost
share. You must have a physician’s prescription
for each OTC tobacco cessation drug.
2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
9
BLUE EXTRAS
Health Club Membership
Other Programs
Finding Care
You pay a $25 initiation fee and $25 monthly for
unlimited visits to over 8,600 fitness facilities
nationwide. You are not limited to a specific facility.
For more information, go to www.fepblue.org.
• WalkingWorks® is a good start for any exercise
routine with a free pedometer and online walking
guide. Visit www.fepblue.org for more information.
National Doctor and Hospital Finder
Our directory of Preferred providers gives you
the control to choose your medical and wellness
specialists while saving you money on medical
costs through our negotiated discounted rates.
Visit www.fepblue.org/provider for details.
• 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.
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.
• 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.
• Care Management Programs, offered by 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.
Blue Distinction Centers®
MyBlue Customer eService
MyBlue Customer eService is like having your own
personal customer service representative when
you need help managing your enrollment. You can
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.
You 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. First,
sign on to www.fepblue.org/myblue.
10
10
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.
2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
BLUE
EXTRAS
Online Explanation of Benefits
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 a
challenge. 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.
11
PHARMACY PROGRAMS
Mail Service Pharmacy Program—
Standard Option Only
Specialty Pharmacy Program—
Both Options
The Mail Service Pharmacy Program for Standard
Option is an easy way to get drugs you take regularly
with the convenience of home delivery.
A specialty prescription drug is used to treat complex
health conditions. Specialty drugs are usually high in
costs and have one or more of these features:
• Are injectable
• Are infused
• Are inhaled
• Are products of biotechnology
• Have special requirements for handling,
shipping and storage
• Need specialized patient training and
coordination of care
If you have any questions about the Mail Service
Pharmacy Program or want to talk to a pharmacist
about your drugs, you can call anytime. This benefit
is not available under Basic Option.
Using the Mail Service
Pharmacy Program is easy.
1. Ask your physician to prescribe up to a 90-day
supply (minimum 22-day supply) of your drug 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 download order forms on www.fepblue.org
or request copies by calling 1-800-262-7890.
Your doctor can order a prescription for you by
calling 1-800-262-7890 and pressing Option 3.
Retail Pharmacy Program—
Both Options
Basic Option members must use a Preferred retail
pharmacy to obtain drugs. 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.
If you have questions about the Specialty Drug
Program call 1-888-346-3731 from 7 a.m. – 9 p.m.
Eastern time, Monday-Friday and 8 a.m. – 6:30 p.m.
Eastern time, Saturday and Sunday.
BENEFIT
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 using the Provider Directory on www.fepblue.org.
2015 STANDARD OPTION COVERAGE
2015 BASIC OPTION COVERAGE
Tier 1 (Generics)*: $15 copayment
Tier 2 (Preferred brand name): $80 copayment
Tier 3 (Non-preferred brand name): $105 copayment
Covers 22-90-day supply
Not a benefit
PRESCRIPTION DRUGS
Mail Service
Pharmacy Program
Nothing for the first 4 prescription fills or refills when
you switch from certain brand name drugs to specific
generic drugs
Retail
Pharmacy Program
Tier 1 (Generics)*: 20% of the Plan allowance
Tier 2 (Preferred brand name): 30% of the Plan allowance
Tier 3 (Non-preferred brand name):
45% of the Plan allowance
Tier 1 (Generics): $10 copayment
Tier 2 (Preferred brand name): $45 copayment
Tier 3 (Non-preferred brand name): 50% of the Plan
allowance with a $55 minimum
Covers up to a 90-day supply
Covers 30-day supply, up to 90-day supply for additional
copayments
Tier 4 (Preferred specialty drugs):
$60 copayment (30-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 Pharmacy
Tier 4 (Preferred specialty drugs):
30% of the Plan allowance (30-day supply)
3. All drugs and instructions are sent via U.S. Postal
Service, except drugs that require overnight
shipping. You should receive your prescription two
weeks from the time you mail in your order.
4. You can order refills by sending in the refill slip
included with your previous prescription fill, online
at www.fepblue.org or by calling 1-877-337-3455,
24 hours a day, seven days a week.
If you have any questions about the Retail Pharmacy
Program, you can call 1-800-624-5060 to talk to a
member service representative.
WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS
Facts to know about specialty drugs
• Specialty drugs in Tier 4 are Preferred.
• Specialty drugs in Tier 5 are Non-preferred.
• Tiers 4 and 5 both have limits on days’ supply
(amount of drug) and where you can get refills.
Just show your Service Benefit Plan ID card at a
Preferred pharmacy. You pay only the appropriate
copayment or coinsurance amount.
Tier 5 (Non-preferred specialty drugs):
30% of the Plan allowance (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.
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.
Tier 4 (Preferred specialty drugs): $35 copayment (30day supply); $95 copayment (90-day supply)
Tier 4 (Preferred specialty drugs): $50 copayment
(30-day supply); $140 copayment (90-day supply)
Tier 5 (Non-preferred specialty drugs):
$55 copayment (30-day supply); $155 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
90-day supply can only be obtained after 3rd fill
PHARMACY
PROGRAMS
Specialty
Pharmacy Program
Tier 5 (Non-preferred specialty drugs):
$80 copayment (30-day supply)
Certain prescription drugs require prior approval.
*Your costs for generic prescription drugs are lower if you have Medicare Part B as your primary coverage.
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2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
13
WORLDWIDE COVERAGE
When You Live or Travel Overseas
How Benefits Work Overseas
Filing Claims
If 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.
Inpatient Hospital Care: Under both options,
benefits are paid at the Preferred level. Precertification
is not required for hospital admissions outside the U.S.
Members can mail claims to us, fax them to us or
submit claims for medical care performed and
prescription drugs purchased overseas through
MyBlue on www.fepblue.org. For information about
mailing and faxing claims to us, see Section 5(i) in the
Service Benefit Plan brochure.
Worldwide Assistance Center
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.
The 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.
Outpatient Hospital Care: Benefits under Standard
and Basic Option are paid at the Preferred level.
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 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.
To submit your claims electronically:
1. Go to www.fepblue.org/myblue and log in if you
have already registered. If not, you will have to set
up a MyBlue account.
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.
2. O
n the MyBlue Welcome page, under Overseas
Assistance, select “Submit an overseas claim.”
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.
• 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.
14
2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
15
WORLDWIDE
COVERAGE
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
Drug 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.
2015 Standard Option and Basic Option
Benefit Comparison Chart
Certain 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
WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS
BENEFIT
2015 STANDARD OPTION COVERAGE*
2015 BASIC OPTION COVERAGE**
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
15% of the Plan allowance
Prior approval is required for
certain surgical services
Subject to calendar year deductible
$150 copayment per performing surgeon in an office visit setting
$200 copayment per performing surgeon in another setting
$250 per admission copayment for unlimited days
$175 per day up to $875 per admission for unlimited days
15% of the Plan allowance
$100 per day per facility copayment
Precertification is required
PRESCRIPTION DRUGS
Certain prescription drugs require prior approval.
Retail Pharmacy Program
Specialty Pharmacy Program
Tier 1 (Generics)***: $15 copayment
Tier 2 (Preferred brand name): $80 copayment
Tier 3 (Non-preferred brand name): $105 copayment
Covers 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
15% of the Plan allowance
Subject 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 angiography, bone density tests, CT scans,
MRIs, PET scans, genetic testing, nuclear medicine and sleep
studies at a professional provider; $150 copayment at a hospital
Accidental injury: Nothing for outpatient, hospital and
physician services within 72 hours
Medical emergency: Regular benefits for physician and
hospital care (Subject to calendar year deductible);
$30 copayment for urgent care center
Accidental injury and medical emergency:
$125 copayment for emergency room care
$35 copayment for urgent care center
Regular benefits for physician care
Inpatient/Outpatient hospital 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 services
Physician care including delivery and pre- and postnatal care:
No out-of-pocket expenses for covered services
EMERGENCY CARE
Accidental injury
Tier 1 (Generics)***: 20% of the Plan allowance
Tier 2 (Preferred brand name): 30% of the Plan allowance
Tier 3 (Non-preferred brand name): 45% of the Plan allowance
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 Pharmacy
Tier 4 (Preferred specialty drugs): 30% of the Plan allowance
(30-day supply)
Tier 5 (Non-preferred specialty drugs): 30% of the Plan
allowance (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.
Tier 1 (Generics): $10 copayment
Tier 2 (Preferred brand name): $45 copayment
Tier 3 (Non-preferred brand name): 50% of the Plan
allowance with a $55 minimum
Covers 30-day supply, up to 90-day supply for additional
copayments
Tier 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.
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
Inpatient/Outpatient hospital care
Precertification is not required
for normal delivery
Physician care
Physician care including delivery and pre- and postnatal care:
No out-of-pocket expenses for covered services
DENTAL CARE
Routine dental care
* When you use Non-preferred hospitals/facilities and professionals, your out-of-pocket expenses are greater. Please see the 2015 Service Benefit Plan
brochure for details.
** Basic Option does not generally provide benefits for services rendered by Non-preferred providers.
*** Your costs for generic prescription drugs are lower if you have Medicare Part B as your primary coverage.
Please see the 2015 Service Benefit Plan brochure for complete details.
16
2015 BASIC OPTION COVERAGE**
MATERNITY CARE
Subject to calendar year deductible
Mail Service Pharmacy Program
Diagnostic test (X-ray, blood work)
Imaging (CT/PET scans, MRIs)
Medical emergency
HOSPITAL/FACILITY CARE
Outpatient hospital/facility care
2015 STANDARD OPTION COVERAGE*
LAB, X-RAY AND OTHER DIAGNOSTIC SERVICES
PHYSICIAN CARE
Hospital inpatient
BENEFIT
Up to age 13: The difference between the fee schedule and
the Maximum Allowable Charge (MAC)
Age 13 and over: The difference between the fee schedule
and the MAC
$25 copayment per evaluation; up to 2 per calendar year
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
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,
copayment and deductible expenses
OTHER BENEFITS
Catastrophic benefits
* When you use Non-preferred hospital/facilities and professionals, your out-of-pocket expenses are greater. Please see the 2015 Service Benefit Plan
brochure for details.
** Basic Option does not generally provide benefits for services rendered by Non-preferred providers.
This is a summary of the features for the Blue Cross and 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 Federal brochure.
As You Make Your Open Season Choices
The 2015 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 2015 brochure at www.fepblue.org.
2015 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary
17
Open Season Dates
The 2014 Open Season for health insurance changes runs from Monday, November 10, 2014 through Monday, December 8, 2014.
2015 Premiums and Rates
2015 Premiums—Your Share
TYPE OF ENROLLMENT
NON-POSTAL PREMIUM
BIWEEKLY
MONTHLY
POSTAL PREMIUM
BIWEEKLY
Category 1
Category 2
Standard Option Self Only (104)
$91.03
$197.23
$77.00
$91.03
Standard Option Self & Family (105)
$213.31
$462.17
$182.16
$213.31
Basic Option Self Only (111)
$63.40
$137.38
$50.09
$63.40
Basic Option Self & Family (112)
$148.46
$321.67
$117.29
$148.46
These rates do not apply to all Enrollees. If you are in a special enrollment category, please refer to the Guide to Federal Benefits or contact the agency
or Tribal Employer which 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 noncareer postal employees. Refer to the applicable Guide to Federal Benefits.
This is a summary of the features for the 2015 Blue Cross and 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 2015 Federal brochure.
Please visit our website 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.