2014
Blue Cross and Blue Shield
Service Benefit Plan
& Medicare Benefits
2014 Blue Cross and Blue Shield Service Benefit
Plan & Medicare Benefit Comparison
Your Blue Cross and Blue Shield Service Benefit Plan plus Medicare coverage work together to maximize your benefits and
STANDARD OPTION
minimize your out-of-pocket costs. These tables highlight some of the most commonly used benefits and the amount you will
BENEFIT
pay when you have Standard or Basic Option, with or without Medicare Parts A and B as your primary carrier(s).
BASIC OPTION
BENEFIT
STANDARD OPTION
STANDARD OPTION
WITH PREFERED PROVIDERS*
WITH PRIMARY MEDICARE A & B
Office visits and outpatient consultations
$20 per visit copayment for primary care provider
$30 per visit copayment for specialists
You pay nothing
Routine exams and other preventive care services
Nothing for covered services
You pay nothing
Surgical services
Prior approval is required for
certain surgical services
15% of the Plan allowance**
You pay nothing
PHYSICIAN CARE
BASIC OPTION
BASIC OPTION
WITH PREFERED PROVIDERS*
WITH PRIMARY MEDICARE A & B
AND PREFERRED PROVIDERS
Office visits and outpatient consultations
$25 per visit copayment for primary care provider
$35 per visit copayment for specialists
You pay nothing
Routine exams and other preventive care services
Nothing for covered services
You pay nothing
Hospital inpatient
Precertification is required
$250 per admission copayment for unlimited days
You pay nothing
Surgical services
Prior approval is required for
certain surgical services
$150 copayment per performing surgeon in an
office setting
$200 copayment per performing surgeon in
another setting
You pay nothing
Outpatient hospital/facility care
15% of the Plan allowance**
You pay nothing
Hospital inpatient
Precertification is required
$175 per day up to $875 per admission for
unlimited days
You pay nothing
Outpatient hospital/facility care
$100 per day facility copayment
You pay nothing
PHYSICIAN CARE
HOSPITAL/FACILITY CARE
PRESCRIPTION DRUGS Certain prescription drugs require prior approval
Mail Service 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
Tier 1 (generics): $10 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
Preferred Retail Pharmacy Program
(For information about Tier 4 and 5 specialty drug
benefits, see Section 5(f) of the 2014 Blue Cross
and Blue Shield Service Benefit Plan brochure)
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 1 (generics): 15% 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
Accidental injury
Nothing for outpatient, hospital and physician
services within 72 hours
You pay nothing
Medical emergency
Regular benefits for physician and hospital care;**
$40 copayment for urgent care center
You pay nothing
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
$5,000 (Self Only) or $6,000 (Self and Family)
out-of-pocket in eligible coinsurance, copayment
and deductible expenses with Preferred providers
CALENDAR YEAR DEDUCTIBLE
$350 per person
$700 per family
The calendar year deductible is waived
HOSPITAL/FACILITY CARE
PRESCRIPTION DRUGS Certain prescription drugs require prior approval
Preferred Retail Pharmacy Program
(For information about Tier 4 and 5 specialty drug
benefits, see Section 5(f) of the 2014 Blue Cross
and Blue Shield Service Benefit Plan brochure)
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 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
$125 copayment for emergency room care
$50 copayment for urgent care center
Regular benefits for physician care
You pay nothing
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
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
EMERGENCY CARE
Accidental injury and medical emergency
EMERGENCY CARE
OTHER BENEFITS
Catastrophic benefits
*Basic Option benefits are not available for services rendered by Non-preferred providers except in certain circumstances, such as emergency care.
Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for complete details.
OTHER BENEFITS
* When you use Non-preferred hospitals/facilities and professionals, your out-of-pocket expenses are greater.
**Subject to the calendar year deductible.
Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for complete details.
Medicare
& Blue.
As you approach age 65, you will have to make
Prescription Drug Coverage
a decision about enrolling in Medicare. This decision
The U.S. Office of Personnel Management has
is voluntary during specific enrollment periods. If
determined that the Blue Cross and Blue Shield
you don’t sign up when you are first eligible, you
Service Benefit Plan’s prescription drug coverage is,
may have to pay a late enrollment penalty.
on average, comparable to Medicare Part D
Medicare Part A (hospital insurance) coverage is
available free of charge to people age 65 and older
who meet the eligibility requirements necessary to
prescription drug coverage. Therefore, you do not
need to enroll in Medicare Part D and pay extra for
prescription drug coverage.
qualify for Social Security benefits. You automatically
Wellness Incentive Program
qualify if you were a federal employee on January 1,
Take steps to better health and earn rewards.
1983. Most people pay a monthly premium for
Complete the 2014 Blue Health Assessment (BHA)
Medicare Part B (medical insurance) coverage.
and earn $40 on your MyBlue® Wellness Card to use
If you have questions about Medicare benefits
or eligibility, call Medicare at 1-800-MEDICARE
(1-800-633-4227) (TTY 1-877-486-2048) or
visit www.medicare.gov.
for qualified medical expenses, such as copayments
and prescription costs. Family contracts are eligible
to receive two $40 cards when two adult members
complete the BHA. After you take the BHA, you can
earn up to $35 more on your card by completing
When you combine Medicare primary coverage with
three lifestyle goals with the Online Health Coach.
your Blue Cross and Blue Shield Service Benefit Plan,
Log in or register at www.fepblue.org/myblue
you have peace of mind that most of your health
to learn more.
and medical costs are covered. To help you
understand the benefits explained in this brochure,
and to understand how benefits are paid without
Medicare coverage or when Medicare is secondary
because you are still working, the 2014 Blue Cross
and Blue Shield Service Benefit Plan brochure (RI
71-005) is available at www.fepblue.org/brochure.
This is a summary of the features of the 2014 Blue Cross and Blue Shield Service Benefit Plan. Before making
a final decision, please read 2014 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005).
All benefits are subject to the definitions, limitations and exclusions set forth in the 2014 brochure.