senior advisor - FEP Blue Cross Blue Shield Federal Employees

4
What’s New for 2016
6
Medicare Coverage
SENIOR ADVISOR
Fall 2015 Newsletter
8
Comparison of Benefits
Dedicated to helping federal employees
stay healthy, save money and get the most
out of the Service Benefit Plan.
www.fepblue.org
TO OUR DEDICATED
FEDERAL EMPLOYEES
Thank you for choosing the Blue Cross and Blue Shield Service Benefit Plan as
your healthcare coverage. We’re committed to providing you and your family the
value you deserve.
With your coverage you receive:
• A member ID card that’s accepted by 96% of hospitals and 92% of professional
providers in the U.S.
• Benefits that are not limited to just the U.S. – you can use them overseas, too.
• Free preventive care when performed by Preferred providers.
• Wellness programs that reward you for choosing to be healthy.
• Additional benefits when you choose to combine our coverage with your
primary Medicare Part A and B coverage.
Get the information you need
With Open Season starting soon—it begins November 9 and ends December 14,
2015—we want to make sure that you know where to go to get all the information
you need about us.
Visit us online: Our website, www.fepblue.org, gives you all the information
you need on our Plan. To get information on 2016 benefits, you can visit our
“What’s New” page at www.fepblue.org/whatsnew. Here you’ll be able to
access our 2016 Blue Cross and Blue Shield Service Benefit Plan brochure and
our benefit summary materials.
Call our Open Season Information Center: We have a dedicated customer
service line available to you during Open Season. Call us at 1-800-411-BLUE
(1-800-411-2583) to ask questions about 2016 benefits or request a Benefits
Information Kit. The Center opens on November 2, 2015 and is open weekdays
from 8 a.m. to 8 p.m.
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A NEW ENROLLMENT TYPE TO FIT YOUR LIFE
Self Plus One covers you and one eligible family member.
We’re committed to making sure your Service Benefit Plan coverage continues to deliver the
exceptional value and peace of mind you’ve come to expect. Part of that is offering the right health
coverage options to fit the needs of you and your family.
Starting in 2016, the federal government will offer Self Plus One, a new enrollment type that allows
you to cover yourself and one eligible family member*. This will be in addition to Self Only and Self
and Family enrollment types available under both Standard and Basic Option. You will be able to
select Self Plus One during the 2015 Open Season enrollment period which begins November 9
and ends December 14, 2015.
The new Self Plus One enrollment codes are:
• Standard Option Self Plus One: 106
• Basic Option Self Plus One: 113
If you want to enroll in Self Plus One you must make this change during Open Season. If you are
retired, you’ll have to use the U.S. Office of Personnel Management’s (OPM’s) online enrollment
system or contact OPM directly if you want to change your enrollment to Self Plus One. If you are
an active employee, you should contact the agency or Tribal Employer that maintains your health
insurance coverage.
To learn more about our enrollment types, visit www.fepblue.org/enrollment. You can also visit
www.opm.gov/selfplusone.
*Your eligible family member can include either a spouse OR a child up to age 26. A child age 26 or over who
is incapable of self-support because of a mental or physical disability that existed before age 26 is also an eligible
family member.
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WHAT’S NEW FOR 2016
Updates and changes to our Plan
Enrollment types
Starting in 2016, the federal government will
offer a new enrollment type, Self Plus One,
in addition to the two other enrollment types:
Self Only and Self and Family.
The new Self Plus One enrollment codes are:
• Standard Option Self Plus One: 106
• Basic Option Self Plus One: 113
See page 3 for more information.
Wellness incentives
• We’ve increased the amount you can earn
when you complete eligible goals with the
Online Health Coach to $40 for each goal
up to three—for a total of $120.
• Expectant mothers can participate in the
new Pregnancy Care Incentive Program
and receive a Pregnancy Care Box and $75
in wellness incentives when they complete
the program requirements.
• Members with high blood pressure can
participate in the Hypertension Management
Program and receive a free blood pressure
monitor when they complete the Blue Health
Assessment (BHA) and indicate they have
high blood pressure.
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Preventive benefits
• Pregnant members can receive low-dose
aspirin to prevent preeclampsia when they
order the drug from a Preferred retail
pharmacy or through the Mail Service
Pharmacy Program.
• Members age 13 and older can receive
one preventive hepatitis B screening per
calendar year.
• Children up to age 5 are eligible for a fluoride
varnish application by a primary care provider.
Limited to two per calendar year.
• Members age 65-75 can receive one
preventive ultrasound for aortic abdominal
aneurysm per lifetime.
• We cover testing for large genomic
rearrangements in the BRCA1 and BRCA2
genes, once per lifetime, for members 18
or older when they meet the criteria for
preventive BRCA.
• We provide one osteoporosis screening
per calendar year for all women 65 and
older and women 50 to 65 at increased risk
for osteoporosis.
• We provide allergy care and prescription drug
benefits for specific FDA-approved allergy
desensitization drugs.
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Dental benefits
Pharmacy benefits
• We changed Standard Option dental benefits
to only include coverage for evaluations,
diagnostic imaging, palliative treatment and
preventive care.
• Basic Option members with Medicare Part B
primary can now order prescription drugs
through the Mail Service Pharmacy.
• We increased the copay for dental care
services for Basic Option members to $30.
Physician and facility services
• We changed our coverage for observation care
in a hospital setting.
• We increased the copay to visit a Preferred
primary care physician to $25 for Standard
Option and $30 for Basic Option.
• We increased the copay for specialty care
providers to $35 for Standard Option and $40
for Basic Option.
• Basic Option members now have a
managed drug formulary instead of an
open drug formulary.
• We’ve increased the cost share for drugs in
Tiers 2 through 5 for Basic Option members
without Medicare Part B primary.
• We provide prescription drug benefits for drugs
used in the treatment of gender identity/
gender dysphoria.
Out-of-pocket maximum
• We increased the copay for inpatient hospital
care and continuous home hospice care at a
Preferred facility for Standard Option members
to $350 per admission or episode.
• Standard Option: The out-of-pocket
maximum for Preferred providers is $5,000
for Self Only contracts and $10,000 for
Self Plus One and Self and Family contracts.
For Non-preferred providers, the Self Only
maximum is $7,000 and the Self Plus One
and Self and Family maximum is $14,000.
• We changed our criteria for coverage of
inpatient care provided by a residential
treatment center.
• Basic Option: The out-of-pocket maximum is
$5,500 for Self Only contracts and $11,000 for
Self Plus One and Self and Family contracts.
• We’ve reduced the cost of outpatient
laparoscopic gastric stapling procedures when
members visit a Blue Distinction Center for
Bariatric Surgery®.
For both Basic and Standard Option Self Plus
One and Self and Family enrollments, once an
individual on the contract reaches the Self Only
out-of-pocket maximum, the maximum is met
for that individual for the remainder of the
calendar year.
•W
e no longer require members to receive
prior approval for intensity modulated radiation
therapy (IMRT) services for the treatment of
anal cancer.
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GET THE MOST OUT OF YOUR
COVERAGE WITH MEDICARE
Medicare is a federal health insurance program for people 65 or older and people under 65
with certain disabilities. When you enroll in Medicare, it pays a large portion of your medical costs,
but it does not cover everything. By combining Medicare with your existing Service Benefit Plan
coverage, you’ll continue to receive the overall value you expect from Blue Cross and Blue Shield.
Medicare Part A and B
Medicare Part A covers inpatient hospital care and is free of charge for individuals eligible
to receive Social Security benefits. Since there’s no additional charge for Part A, many federal
employees choose to enroll in this coverage.
Medicare Part B covers many of the services not covered by Part A, such as outpatient care and
physician services. There is a premium and annual deductible for Part B. However, if you choose to
enroll in Part B and keep your Service Benefit Plan coverage, we’ll pay your annual deductible and
many of the out-of-pocket costs for services that are included in your covered benefits.
If you choose to enroll in Medicare Part A and B and combine them with your Service Benefit Plan
coverage, you receive many additional benefits when Medicare is your primary insurance, which
means it pays first. See the charts on pages 8-9 to see what you pay for certain services if you visit
Preferred providers and combine your coverage.
Prescription benefits
You still have to pay your prescription drug cost share amounts under both Standard and
Basic Option; however, we offer you additional benefits under each coverage type if you have
Medicare Part B primary.
For Standard Option, you pay a lower cost share amount for generic drugs using both a
Preferred retail pharmacy or the Mail Service Pharmacy Program. See pages 8-9 for specific cost
share amounts.
2016
If you have Basic Option, you can order your prescription drugs through the Mail Service Pharmacy
if you combine your Service Benefit Plan coverage with your primary Medicare Part B coverage.
Basic Option members without Medicare Part B primary cannot use the Mail Service Pharmacy.
See pages 8-9 for specific cost share amounts.
Learn more about combining Medicare and Service Benefit Plan coverage at
www.fepblue.org/medicare.
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EVERYTHING YOU NEED TO STAY WELL,
AND THEN SOME
At Blue Cross and Blue Shield, we don’t just
help you pay your healthcare bills, we care
about your wellbeing. That’s why we give you
tools, resources, support, and even rewards to
help you stay well.
Diabetes Management Incentive Program
– Earn up to $75
Earn up to $75 through the Diabetes
Management Incentive Program when you
complete specific activities to help manage
your diabetes.
2016 Wellness Incentive Program –
Better health, and then some.
Tobacco Cessation Incentive Program
When you complete the BHA and create a
tobacco Quit Plan through the Online Health
Coach, you can receive tobacco cessation
products at no cost. You can receive certain
prescription and over-the-counter (OTC)
tobacco cessation products as long as you use
a Preferred retail pharmacy.
Blue Health Assessment – Earn $50
In 2016, you’ll earn $50 when you complete
the Blue Health Assessment (BHA). Simply
answer questions related to your health,
and in just 10 minutes, receive a confidential,
personalized plan for moving forward.
2016
Online Health Coach – Earn up to $120
With your personalized plan from the Online
Health Coach, you’ll earn rewards—up to
$120—when you achieve certain goals. In
2016, we’re expanding the eligible goals to
include both wellness goals, like exercising
more, and condition management goals, such
as managing heart disease. Earn $40 for each
eligible goal you complete, up to three.
NEW: Automatic Fitness Device Tracking—
if you use a Fitbit, you can now sync your
device to Health Tools to automatically track
your progress for certain Online Health Coach
goals. It will also automatically sync to your
Personal Health Record (PHR).
2016
Hypertension Management Program
Knowing your blood pressure numbers is
important—especially if your doctor says you
have hypertension (high blood pressure).
If you have hypertension and you indicate that
on the BHA, you may be eligible to receive a
blood pressure monitor at no out-of-pocket
cost to you. With your blood pressure monitor
you can make monitoring your blood pressure
numbers at home part of your hypertension
management routine.
Learn more about your wellness incentives and additional wellness programs at
www.fepblue.org/healthwellness.
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2016 COMPARISON OF BENEFITS
Standard Option
WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS
BENEFIT
WELLNESS INCENTIVE PROGRAM
Standard Option
PREVENTIVE CARE
PHYSICIAN CARE
2016 Standard Option
2016 Standard Option with
Primary Medicare A & B
Earn $50 for completing the Blue Health Assessment and up to $120 for achieving up to three
eligible Online Health Coach goals. Learn more at www.fepblue.org.
You pay nothing
You pay nothing
$25 per visit copayment for primary care providers
$35 per visit copayment for specialists
You pay nothing.
LAB, X-RAY & OTHER
DIAGNOSTIC SERVICES
15%* of the Plan allowance
You pay nothing
HOSPITAL CARE
Inpatient: $350 per admission
Outpatient: 15%* of the Plan allowance
You pay nothing
SURGICAL SERVICES
15%* of the Plan allowance
You pay nothing
URGENT CARE
$30 copayment for urgent care center
You pay nothing
EMERGENCY CARE
Accidental Injury: Nothing for outpatient,
hospital and physician services within 72 hours
Medical Emergency: Regular benefits for
physician and hospital care*
You pay nothing
Preferred Retail Pharmacy:
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
Preferred Retail Pharmacy:
Tier 1 (Generics): 15% 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
Mail Service Pharmacy:
Tier 1 (Generics): $15 copayment
Tier 2 (Preferred brand name): $80 copayment
Tier 3 (Non-preferred brand name):
$105 copayment
Mail Service Pharmacy:
Tier 1 (Generics): $10 copayment
Tier 2 (Preferred brand name): $80 copayment
Tier 3 (Non-preferred brand name):
$105 copayment
Specialty Pharmacy:
Please see the Blue Cross and Blue Shield Service
Benefit Plan brochure for information on the
Specialty Pharmacy Program.
Specialty Pharmacy:
Please see the Blue Cross and Blue Shield Service
Benefit Plan brochure for information on the
Specialty Pharmacy Program.
CHIROPRACTIC/OSTEOPATHIC
MANIPULATIVE TREATMENT
$25 copayment per visit; up to a combined
12 manipulations per year
You pay nothing
OUT-OF-POCKET MAXIMUM
Preferred provider services: Your out-of-pocket
maximum is $5,000 for Self Only and $10,000 for
Self + One and Self & Family contracts
Preferred provider services: Your out-of-pocket
maximum is $5,000 for Self Only and $10,000 for
Self + One and Self & Family contracts
CALENDAR YEAR DEDUCTIBLE
$350 per person
$700 per family
The calendar year deductible is waived
PRESCRIPTION DRUGS
* Is subject to the 2016 Standard Option calendar year deductible.
If you use a Non-preferred physician or other healthcare professional under Standard Option, you generally pay any difference between our allowance and the billed amount,
in addition to any share of our allowance shown in the table above.
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2016 COMPARISON OF BENEFITS
Basic Option
WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS
BENEFIT
WELLNESS INCENTIVE PROGRAM
2016 Basic Option
2016 Basic Option with
Primary Medicare A & B
Earn $50 for completing the Blue Health Assessment and up to $120 for achieving up to three
eligible Online Health Coach goals. Learn more at www.fepblue.org.
PREVENTIVE CARE
You pay nothing
You pay nothing
PHYSICIAN CARE
$30 per visit copayment for primary care providers
$40 per visit copayment for specialists
You pay nothing
LAB, X-RAY & OTHER DIAGNOSTIC
SERVICES
$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
You pay nothing
HOSPITAL CARE
Inpatient: $175 per day up to $875 per admission
Outpatient: $100 per day per facility
You pay nothing
SURGICAL SERVICES
$150 copayment when performed in an office
setting; $200 copayment when performed in
non-office setting
You pay nothing
URGENT CARE
$35 copayment for urgent care center
You pay nothing
EMERGENCY CARE
Accidental Injury and Medical Emergency:
$125 copayment for emergency room care
Regular benefits for physician care
You pay nothing
PRESCRIPTION DRUGS
Preferred Retail Pharmacy:
Tier 1 (Generics): $10 copayment
Tier 2 (Preferred brand name): $50 copayment
Tier 3 (Non-preferred brand name): 60% of the
Plan allowance ($65 minimum)
Mail Service Pharmacy:
Not a benefit
Specialty Pharmacy:
Please see the Blue Cross and Blue Shield Service
Benefit Plan brochure for information on the
Specialty Pharmacy Program.
Preferred Retail Pharmacy:
Tier 1 (Generics): $10 copayment
Tier 2 (Preferred brand name): $45 copayment
Tier 3 (Non-preferred brand name): 50% of the
Plan allowance ($55 minimum)
Mail Service Pharmacy:
Tier 1 (Generics): $20 copayment
Tier 2 (Preferred brand name): $90 copayment
Tier 3 (Non-preferred brand name):
$115 copayment
Specialty Pharmacy:
Please see the Blue Cross and Blue Shield Service
Benefit Plan brochure for information on the
Specialty Pharmacy Program.
CHIROPRACTIC/OSTEOPATHIC
MANIPULATIVE TREATMENT
$30 copayment per visit; up to a combined
20 manipulations per year
You pay nothing
OUT-OF-POCKET MAXIMUM
Preferred provider services: Your out-of-pocket
maximum is $5,500 for Self Only and $11,000 for
Self + One and Self & Family contracts
Preferred provider services: Your out-of-pocket
maximum is $5,500 for Self Only and $11,000 for
Self + One and Self & Family contracts
CALENDAR YEAR DEDUCTIBLE
No deductible
No deductible
Basic Option generally does not provide benefits when you use Non-preferred providers.
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WE’RE HERE FOR YOU
Additional Resources
Don’t let your questions go unanswered
this Open Season. Here’s where you can go
to learn more.
Learn what’s new with the Service Benefit
Plan at www.fepblue.org/whatsnew.
Here you’ll find the information you need on the
changes we’re making for 2016. You’ll be able
to access our 2016 Blue Cross and Blue Shield
Service Benefit Plan brochure as well as
additional benefit materials. You’ll also learn
about other features and services that we offer.
Find a doctor at www.fepblue.org/provider.
We have a large network of Preferred providers.
To find a provider in your area, use our provider
directory on our website. You can also
download the National Doctor and Hospital
Finder app to find Preferred providers on the go.
Download the provider app on the App Store or
Google Play Store today.
Find out more about the coverage choices
available to you at askblue.fepblue.org.
CALL THE NURSE LINE
at 1-888-258-3432 if you need
health advice. Nurses are
available 24 hours a day, seven
days a week. You can also chat
or email a nurse online once
you register for MyBlue.
If you want to see if you’re in the right coverage
option—you can use AskBlue for Federal
Employees to help you choose the correct
coverage and enrollment type for your family.
AskBlue will ask you a series of questions to
learn more about your healthcare needs.
Once it understands those needs, the tool will
give you advice to help you choose the right
coverage for you and your family.
Learn more about our health
and wellness programs at
www.fepblue.org/healthwellness.
Our Open Season Information Center
is available to answer your questions
about our benefits and coverage options.
We want you to live your life well. That’s why
we offer a wide range of health and wellness
programs. Find out more about the programs
we offer you on our website.
The Center opens on November 2, 2015.
Call us Monday through Friday from
8 a.m. to 8 p.m. at 1-800-411-BLUE (2583)
to speak to a representative.
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2016 RATE INFORMATION
Standard Option Rates – Your Share
Non-Postal
Premium
TYPE OF
ENROLLMENT
Postal
Premium
BIWEEKLY
MONTHLY
BIWEEKLY
Category 1
BIWEEKLY
Category 2
Self Only (104)
$100.18
$217.06
$88.32
$100.18
Self + One (106)
$231.31
$501.17
$205.70
$231.31
Self & Family (105)
$238.24
$516.18
$211.10
$238.24
Basic Option Rates – Your Share
Non-Postal
Premium
TYPE OF
ENROLLMENT
Postal
Premium
BIWEEKLY
MONTHLY
BIWEEKLY
Category 1
BIWEEKLY
Category 2
Self Only (111)
$68.48
$148.38
$56.84
$68.48
Self + One (113)
$160.75
$348.29
$135.14
$160.75
Self & Family (112)
$164.20
$355.76
$137.06
$164.20
These rates do not apply to all Enrollees. If you are in a special enrollment
category, please contact the agency or Tribal Employer which maintains your
health benefits enrollment.
We’re here with you every step of the way.
Learn more about benefits, wellness incentives and more at www.fepblue.org.
24/7 Nurse Line
1-888-258-3432
Retail Pharmacy
1-800-624-5060
Mail Service Pharmacy
1-800-262-7890
Overseas Assistance
1-800-699-4337 (U.S., Puerto Rico,
or the U.S. Virgin Islands)
1-804-673-1678 (Outside the U.S.)
This is a summary of the features of the 2016 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.
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