2014 B Lue Cros S And Blue Shield Service Benefit Plan

2014 Blue Cross and Blue Shield
Service Benefit Plan Comparison of Benefits
Benefit
2014 STANDARD OPTION PPO
2014 BASIC OPTION – In-Network Only
REFERRALS
Not Required
Not Required
Wellness incentive
Program
Earn up to $75 for completing wellness incentives. Earn up to $75 for completing wellness incentives.
This incentive can be earned by up to 2 members This incentive can be earned by up to 2 members
over the age of 18 per family contract.
over the age of 18 per family contract.
Preventive CARE
FREE
FREE
• Adult and well child care (up
to age 22) routine physicals
and preventive services
No out-of-pocket expenses for covered services
No out-of-pocket expenses for covered services
Physician Care
$20 copayment per office visit for primary care provider; $25 copayment per office visit for primary care provider;
$35 copayment per office visit for specialists
$30 copayment per office visit for specialists
Lab, x-ray & other
diagnostic services
15%* of the Plan allowance
$0 Copayment – Blood Tests, EKGs, Lab Tests,
Pathology Services and Urinalysis
$40 Copayment – EEGs, Ultrasounds, X-Rays
(including set-up of equipment)
$100 Copayment – Bone Density Tests, Sleep Studies, CT
Scans, MRIs, PET Scans, Diagnostic Angiography, Genetic
Testing and Nuclear Medicine; $150 copayment at a hospital
• Inpatient
• Outpatient
$250 per admission
$175 per day up to $875 per admission
15%* of the Plan allowance
$100 per day per facility
Surgery
15%* of the Plan allowance
$150 copayment per performing surgeon in an office
setting; $200 copayment per performing surgeon in a
non-office setting
• Inpatient/Outpatient hospital
care (pre-certification is not
required for normal delivery)
No out-of-pocket expenses for covered services
$175 copayment per Inpatient admission
No out-of-pocket expenses for Outpatient covered
services
• Physician care including delivery
and pre- and post-natal care
No out-of-pocket expenses for covered services
No out-of-pocket expenses for covered services
Urgent CARE
$40 copayment for urgent care per visit
$50 copayment for urgent care per visit
• Accidental Injury
Nothing for outpatient hospital and physician
services within 72 hours; regular benefits thereafter
$125 copayment for emergency room care
• Medical Emergency
Regular benefits for physician and hospital care*
Same as for accidental injury
PRESCRIPTION Care
All prescription drugs covered up to a 90-day supply.
Retail Pharmacy:
Tier 1: (Generic) 20% of the Plan allowance.
Tier 2: (Brand name) 30% of the Plan allowance.
Tier 3: (Non-preferred brand name) 45% of the
Plan allowance.
Mail Service:
Tier 1: (Generic) $15 copayment.
Tier 2: (Preferred brand name) $80 copayment.
Tier 3: (Non-preferred brand name) $105 copayment.
For information regarding the Specialty Pharmacy
Program, please refer to the 2014 Blue Cross and
Blue Shield Service Benefit Plan brochure (RI 71-005).
Covers 30-day supply, up to 90-day supply for additional
copayments.
CHIROPRACTIC/
Osteopathic CARE
$20 copayment per visit; up to a combined
12 manipulative treatments per calendar year
$25 copayment per visit; up to a combined
20 manipulative treatments per calendar year
DENTAL CARE
Limited
Preventive, fillings and extractions
$25 copayment per office visit
Preventive care only
HOSPITAL CARE
• Inpatient/Outpatient
Physician Care
Maternity CARE
EMERGENCY CARE
PPO: Member pays an out-of-pocket maximum
PROTECTION AGAINST
CATASTROPHIC Protection of $5,000 for Self Only and $6,000 for Self and
(your out-of-pocket maximum)
Family plan.
Retail Pharmacy Only
Tier 1: (Generic) $10 copayment.
Tier 2: (Preferred brand name) $45 copayment.
Tier 3: (Non-preferred brand name) 50% of the Plan
allowance. ($55 minimum).
Mail Service is not a benefit.
For information regarding the Specialty Pharmacy
Program, please refer to the 2014 Blue Cross and
Blue Shield Service Benefit Plan brochure (RI 71-005).
PPO: Member pays an out-of-pocket maximum of
$5,500 for Self Only and $7,000 for Self and Family plan.
SBPSDBYSD14
*Is subject to the calendar year deductible: $350 per person or $700 per family for 2014 Standard Option: No deductible for 2014 Basic
Option. If you use a Non-PPO physician or other health care 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. Basic Option does not provide benefits when you use Non-PPO providers.
Do not rely on this chart alone. This is a summary of the features of 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. For a contractual and complete description of the benefits available under the Service Benefit Plan, please refer to the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure.
2014 Rates & Options
Standard
Option
Non-Postal Premium
Rates
Postal Premium
Category 1
Category 2
B a s i c
O p t i o n
Non-Postal Premium
R at e s
Postal Premium
Category 1
Category 2
BiweeklyMonthly Biweekly Biweekly
BiweeklyMonthly Biweekly Biweekly
CodeYourYourYourYour
ShareShareShareShare
CodeYourYourYourYour
ShareShareShareShare
Self
Only
Self
Only
104 $87.82$190.28 $65.96 $79.62
Self & 105 $204.98$444.12 $156.36 $186.75
Family
111 $60.96$132.09 $40.24 $53.04
Self & 112 $142.75$309.30 $94.22 $124.20
Family
These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to your special FEHB Guide or contact the agency which maintains your health benefits enrollment.
Standard Option
Enrollment Codes (104 – 105)
Vision Care Affinity Program
1-800-551-3337
Basic Option
Enrollment Codes (111 – 112)
Retail Pharmacy
1-800-624-5060
Mail Order Prescription
1-800-262-7890
Overseas
1-800-699-4337 (U.S./Puerto Rico only)
or call collect at: 1-804-673-1678 (all other countries)
For information about Blue Health Assessment and
WalkingWorks® visit www.fepblue.org
SM
More benefits. More peace of mind.