Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary

Transcription

1 VALUE OF BLUE BASIC OPTION STANDARD OPTION NEW HEALTH TOOLS REWARD PROGRAMS Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary 2014 BLUE EXTRAS PHARMACY PROGRAMS WORLDWIDE COVERAGE

2 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 (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: If you would like to talk to someone about your questions, you can call our Open Season Information Center at BLUE beginning October 21 through December 20,

3 Basic Option Network Providers Under Basic Option, you must use Preferred providers for Benefits are only available for care performed by all the medical care you and your family need. Preferred Non-preferred providers in certain situations, such providers file your claims, and payment will be made to as emergency care. the provider. EXAMPLE OF YOUR COSTS WHEN YOU USE PREFERRED PROVIDERS 2014 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 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for more information. (Brochure sections are identified for your reference.) WHAT YOU PAY SERVICES PREVENTIVE CARE 5(a) and 5(h) Preventive screenings and related office visit charge; routine physical exams Preventive care for children, up to age 22 Routine dental care PHYSICIAN CARE 5(a) and 5(b) 2014 BASIC OPTION NETWORK BENEFIT* Nothing for an annual physical and covered preventive screenings Nothing for covered services $25 copayment per evaluation up to 2 per calendar year Preventive care only 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 Surgical care Office visits, consultations and second surgical opinions MATERNITY CARE 5(a) Inpatient/Outpatient hospital care (Precertification is not required for normal delivery) Physician care HOSPITAL/FACILITY CARE 5(c) Inpatient hospital/facility care Precertification is required Outpatient hospital/facility care ACCIDENTAL INJURY/MEDICAL EMERGENCY 5(d) Accidental injury and medical emergency $150 copayment per performing surgeon in an office setting $200 copayment per performing surgeon in another setting $25 per visit copayment for primary care provider $35 per visit copayment for specialists $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 $175 per day up to $875 per admission for unlimited days $100 per day per facility copayment $125 copayment for emergency room care $50 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 3

4 Standard Option More Choices 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. EXAMPLE OF YOUR SAVINGS WHEN YOU USE PREFERRED PROVIDERS DIAGNOSTIC TEST (SUCH AS AN X-RAY OR BLOOD WORK) PREFERRED PROVIDER PARTICIPATING PROVIDER Physician s charge $250 $250 $250 Plan allowance $100 $100 $100 NON-PARTICIPATING PROVIDER 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 YOUR TOTAL ESTIMATED PAYMENT $0 $0 $150 $15 $35 $ Standard 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 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for more information. (Brochure sections are identified for your reference.) WHAT YOU PAY SERVICES PREVENTIVE CARE 5(a) AND 5(h) Preventive screenings and related office visit charge; routine physical exams 2014 STANDARD OPTION PPO BENEFIT Nothing for an annual physical and covered preventive screenings 2014 STANDARD OPTION NON-PPO BENEFIT* 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 PHYSICIAN CARE 5(a) AND 5(b) 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 MATERNITY CARE 5(a) Inpatient/Outpatient hospital care (Precertification is not required for normal delivery) Physician Care HOSPITAL/FACILITY CARE 5(c) Inpatient hospital/facility care Precertification is required $20 per visit copayment for primary care provider $30 per visit copayment for specialists No out-of-pocket expenses for covered services No out-of-pocket expenses for covered services $250 per admission copayment for unlimited days 35% of the Plan allowance** $350 per admission copayment plus 35% of the Plan allowance 35% of the Plan allowance** $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 Medical emergency/professional care OTHER BENEFITS 4 Emergency room: 15% of the Plan allowance** Urgent care center: $40 copayment $20 per visit copayment for primary care provider $30 per visit copayment for specialists Emergency room: 15% of the Plan allowance** Urgent care center: 35% of the Plan allowance** 35% of the Plan allowance** STANDARD OPTION 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 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. 4 5

5 New Health Tools on MyBlue New year, new start! Blue has you covered! All-New Health Tools on MyBlue Website MyBlue 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! 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. Start Here: Blue Health Assessment What 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 Coach It 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 the Nurse Line for reliable health information, anytime day or night. Visit or call 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 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 NEW HEALTH TOOLS the Nurse Line, too! *Seek immediate medical attention for life-threatening health issues. 6 7

6 Reward Programs MyBlue Wellness Card The 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 , any new credits will be applied to your existing card. More benefits. More peace of mind. Diabetes Management Incentive Program 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 EARN $20 $10 $40 $10 WHEN YOU 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 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 Extra Motivation! Take steps toward better health and earn up to $75* EARN 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. WHEN YOU $40 Complete the Blue Health Assessment $15 $10 $10 Achieve your first goal with the Online Health Coach** Achieve your second goal with the Online Health Coach** Achieve your third goal with the Online Health Coach** ** Goals must be started and completed within the calendar year. 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. $20 $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 Tobacco Cessation 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. REWARD PROGRAMS 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. 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. 8 9

7 Blue Extras Health Club Membership Other Programs Finding Care 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 WalkingWorks is a good start for any exercise routine with a free pedometer and online walking guide. Visit for more information. National 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 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 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 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 for additional information about this program or call 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 eservice MyBlue 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 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. Sign on to 10 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 BLUE EXTRAS Online Explanation of Benefits Blue Distinction Centers 11

8 Pharmacy Programs 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 or by calling You can also ask your doctor to order a prescription for you by calling this number and pressing Option 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 under Pharmacy to request the refill or by calling hours a day, seven days a week. Retail Pharmacy Program Both Options Basic 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 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 or by visiting the Pharmacy section on WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS BENEFIT 2014 STANDARD OPTION COVERAGE 2014 BASIC OPTION COVERAGE PRESCRIPTION DRUGS Mail Service Pharmacy Preferred Retail Pharmacy Program Tier 1 (generics)*: $15 copayment Tier 2 (Preferred brand name): $80 copayment Tier 3 (Non-preferred brand name): $105 copayment Covers day supply Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs Tier 1 (generics)*: 20% coinsurance Tier 2 (Preferred brand name): 30% coinsurance Tier 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 Pharmacy Tier 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. Not a benefit Tier 1 (generics): $10 copayment Tier 2 (Preferred brand name): $45 copayment Tier 3 (Non-preferred brand name): 50% coinsurance 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 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 Certain prescription drugs require prior approval. *Benefits for generic prescription drugs are different if you have Medicare Part B as your primary coverage. 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 PHARMACY PROGRAMS 12 13

9 Worldwide Coverage When You Live or Travel Overseas How Benefits Work Overseas Filing Claims You can also take advantage of bank wire payment 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. Worldwide Assistance Center 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. Inpatient 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. Members 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 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. 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. The Center can help you locate a provider. You can call the Center collect at or fepoverseas@axa-assistance.us for help. 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 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. 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. 14 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 or filing it via our website at 15 WORLDWIDE COVERAGE

10 2014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Comparison 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 BENEFIT 2014 STANDARD OPTION COVERAGE* 2014 BASIC OPTION COVERAGE** PHYSICIAN CARE Office visits and outpatient consultations Routine exams and other preventive care services Surgical services Prior approval is required for certain surgical services HOSPITAL/FACILITY CARE Hospital inpatient Precertification is required Outpatient hospital/facility care PRESCRIPTION DRUGS Certain prescription drugs require prior approval. Mail Service Pharmacy Program Preferred Retail Pharmacy Program Specialty Pharmacy Program $20 per visit copayment for primary care provider $30 per visit copayment for specialists Nothing for covered services 15% of the Plan allowance Subject to calendar year deductible $25 per visit copayment for primary care provider $35 per visit copayment for specialists Nothing for covered services $150 copayment per performing surgeon in an office 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 Subject to calendar year deductible Tier 1 (generics)***: $15 copayment Tier 2 (Preferred brand name): $80 copayment Tier 3 (Non-preferred brand name): $105 copayment Covers day supply Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs Tier 1 (generics)***: 20% coinsurance Tier 2 (Preferred brand name): 30% coinsurance Tier 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 Pharmacy Tier 4 (Preferred specialty drugs): 30% coinsurance Tier 5 (Non-preferred specialty drugs): 30% coinsurance 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 $100 per day facility copayment Not a benefit Tier 1 (generics): $10 copayment Tier 2 (Preferred brand name): $45 copayment Tier 3 (Non-preferred brand name): 50% coinsurance 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): $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) EMERGENCY CARE Accidental injury Medical emergency MATERNITY CARE Inpatient/Outpatient hospital care Precertification is not required for normal delivery Physician care DENTAL CARE Routine dental care 15% of the Plan allowance Subject to calendar year deductible 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); $40 copayment for urgent care center 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 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 CHIROPRACTIC/OSTEOPATHIC MANIPULATIVE TREATMENT $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 Accidental injury and medical emergency: $125 copayment for emergency room care $50 copayment for urgent care center Regular benefits for physician care 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 $25 copayment per evaluation up to 2 per calendar year Preventive care only 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. As You Make Your Open Season Choices 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

11 Open Season Dates The 2013 Open Season for health insurance changes runs from Monday, November 11, 2013, through Monday, December 9, Premiums and Rates 2014 Premiums Your Share NON-POSTAL PREMIUM POSTAL PREMIUM TYPE OF ENROLLMENT BIWEEKLY MONTHLY BIWEEKLY Category 1 Category 2 Standard Option Self Only (104) $87.82 $ $65.96 Standard Option Family (105) $ $ $ Basic Option Self Only (111) $60.96 $ $40.24 Basic Option Family (112) $ $ $94.22 $79.62 $ $53.04 $ 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 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 ). All benefits are subject to the definitions, limitations and exclusions set forth in the 2014 brochure. Please visit our web site 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.