2014 B lue Cros s and Blue shield Service Benefit Plan ... · Program, please refer to the 2014...
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2014 B LUE CROS S AND BLUE SHIELD Service Benefit Plan Comparison of Benefits *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. SBPSDBYSD14 BENEFIT 2014 STANDARD OPTION PPO 2014 BASIC OPTION – In-Network Only REFERRALS WELLNESS INCENTIVE PROGRAM PREVENTIVE CARE • Adult and well child care (up to age 22) routine physicals and preventive services PHYSICIAN CARE LAB, X-RAY & OTHER DIAGNOSTIC SERVICES HOSPITAL CARE • Inpatient • Outpatient SURGERY • Inpatient/Outpatient Physician Care MATERNITY CARE • Inpatient/Outpatient hospital care (pre-certification is not required for normal delivery) • Physician care including delivery and pre- and post-natal care URGENT CARE EMERGENCY CARE • Accidental Injury • Medical Emergency PRESCRIPTION CARE CHIROPRACTIC/ OSTEOPATHIC CARE DENTAL CARE PROTECTION AGAINST CATASTROPHIC PROTECTION (your out-of-pocket maximum) Not Required Earn up to $75 for completing wellness incentives. This incentive can be earned by up to 2 members over the age of 18 per family contract. FREE No out-of-pocket expenses for covered services $25 copayment per office visit for primary care provider; $35 copayment per office visit for specialists $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 $175 per day up to $875 per admission $100 per day per facility $150 copayment per performing surgeon in an office setting; $200 copayment per performing surgeon in a non-office setting $175 copayment per Inpatient admission No out-of-pocket expenses for Outpatient covered services No out-of-pocket expenses for covered services $50 copayment for urgent care per visit $125 copayment for emergency room care Same as for accidental injury Covers 30-day supply, up to 90-day supply for additional copayments. 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). $25 copayment per visit; up to a combined 20 manipulative treatments per calendar year $25 copayment per office visit Preventive care only PPO: Member pays an out-of-pocket maximum of $5,500 for Self Only and $7,000 for Self and Family plan. Not Required Earn up to $75 for completing wellness incentives. This incentive can be earned by up to 2 members over the age of 18 per family contract. FREE No out-of-pocket expenses for covered services $20 copayment per office visit for primary care provider; $30 copayment per office visit for specialists 15%* of the Plan allowance $250 per admission 15%* of the Plan allowance 15%* of the Plan allowance No out-of-pocket expenses for covered services No out-of-pocket expenses for covered services $40 copayment for urgent care per visit Nothing for outpatient hospital and physician services within 72 hours; regular benefits thereafter Regular benefits for physician and hospital 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). $20 copayment per visit; up to a combined 12 manipulative treatments per calendar year Limited Preventive, fillings and extractions PPO: Member pays an out-of-pocket maximum of $5,000 for Self Only and $6,000 for Self and Family plan.
Transcript of 2014 B lue Cros s and Blue shield Service Benefit Plan ... · Program, please refer to the 2014...
2 0 1 4 B l u e C r o s s a n d B l u e s h i e l dService Benefit Plan Comparison of Benefits
*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.
SB
PS
DB
YS
D14
Benefit 2014 StAnDARD OPtiOn PPO 2014 BASiC OPtiOn – in-network Only
RefeRRALS
WeLLneSS inCentivePROgRAm
PReventive CARe• Adult and well child care (up to age 22) routine physicals and preventive services
PhySiCiAn CARe
LAB, x-RAy & OtheRDiAgnOStiC SeRviCeS
hOSPitAL CARe• Inpatient
• Outpatient
SuRgeRy• Inpatient/Outpatient Physician Care
mAteRnity CARe• Inpatient/Outpatient hospital care (pre-certification is not required for normal delivery)
• Physician care including delivery and pre- and post-natal care
uRgent CARe
emeRgenCy CARe• Accidental Injury
• Medical Emergency
PReSCRiPtiOn CARe
ChiROPRACtiC/OSteOPAthiC CARe
DentAL CARe
PROteCtiOn AgAinStCAtAStROPhiC PROteCtiOn(your out-of-pocket maximum)
not Required
Earn up to $75 for completing wellness incentives. This incentive can be earned by up to 2 members over the age of 18 per family contract.
Free
No out-of-pocket expenses for covered services
$25 copayment per office visit for primary care provider; $35 copayment per office visit for specialists
$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
$175 per day up to $875 per admission
$100 per day per facility
$150 copayment per performing surgeon in an office setting; $200 copayment per performing surgeon in a non-office setting
$175 copayment per Inpatient admissionNo out-of-pocket expenses for Outpatient covered services
No out-of-pocket expenses for covered services
$50 copayment for urgent care per visit
$125 copayment for emergency room care
Same as for accidental injury
Covers 30-day supply, up to 90-day supply for additionalcopayments.
Retail Pharmacy OnlyTier 1: (Generic) $10 copayment.Tier 2: (Preferred brand name) $45 copayment.Tier 3: (Non-preferred brand name) 50% of the Planallowance. ($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).
$25 copayment per visit; up to a combined 20 manipulative treatments per calendar year
$25 copayment per office visitPreventive care only
PPO: Member pays an out-of-pocket maximum of $5,500 for Self Only and $7,000 for Self and Family plan.
not Required
Earn up to $75 for completing wellness incentives. This incentive can be earned by up to 2 members over the age of 18 per family contract.
Free
No out-of-pocket expenses for covered services
$20 copayment per office visit for primary care provider;$30 copayment per office visit for specialists
15%* of the Plan allowance
$250 per admission
15%* of the Plan allowance
15%* of the Plan allowance
No out-of-pocket expenses for covered services
No out-of-pocket expenses for covered services
$40 copayment for urgent care per visit
Nothing for outpatient hospital and physicianservices within 72 hours; regular benefits thereafter
Regular benefits for physician and hospital 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).
$20 copayment per visit; up to a combined 12 manipulative treatments per calendar year
LimitedPreventive, fillings and extractions
PPO: Member pays an out-of-pocket maximum of $5,000 for Self Only and $6,000 for Self and Family plan.
2014 Rates & OptiOns
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 Optionenrollment Codes (104 – 105)
Basic Optionenrollment Codes (111 – 112)
vision Care Affinity Program1-800-551-3337
mail Order Prescription1-800-262-7890
Retail Pharmacy1-800-624-5060
Overseas1-800-699-4337 (U.S./Puerto Rico only)
or call collect at: 1-804-673-1678 (all other countries)
For information about Blue health AssessmentSm and
WalkingWorks® visit www.fepblue.org
s t a n d a r d o p t i o n r a t e s non-postal postal premium premium Category 1 Category 2
Biweekly Monthly Biweekly Biweekly
Code your your your your share share share share
self 104 $87.82 $190.28 $65.96 $79.62only
self & 105 $204.98 $444.12 $156.36 $186.75Family
B a s i C o p t i o n r a t e s non-postal postal premium premium Category 1 Category 2
Biweekly Monthly Biweekly Biweekly
Code your your your your share share share share
self 111 $60.96 $132.09 $40.24 $53.04only
self & 112 $142.75 $309.30 $94.22 $124.20Family
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