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Compare Benefit Options

The Service Benefit Plan offers two types of coverage: Standard Option and Basic Option. Standard Option gives you the freedom to receive covered services from both Preferred and Non-preferred providers. Basic Option members must receive care performed by Preferred providers, except in certain situations like emergency care. Standard Option also has a calendar year deductible, while Basic Option does not. Most care under Basic Option is subject to a copayment amount.

2012 Premiums — Your Share

This is a summary of the features for the 2012 Blue Cross and Blue Shield Service Benefit Plan. All benefits are subject to the definitions, limitations and exclusions set forth in the 2012 Benefit Plan brochure.

If you are a tribal employee, please note that rates may vary for you. Contact your Human Resources representative for additional information or to inquire about enrolling.

2012 Standard Option2012 Basic Option
Non-Postal Premium
Biweekly
  • Self Only (104): $85.58
  • Family (105): $198.48
  • Self Only (111): $56.25
  • Family (112): $131.73
Non-Postal Premium
Monthly
  • Self Only (104): $185.42
  • Family (105):$430.04
  • Self Only (111):$121.88
  • Family (112):$285.42
 Category 1Category 2Category 1Category 2
Postal Premium
Biweekly
  • Self Only (104): $64.95
  • Family (105): $152.44
  • Self Only (104): $62.37
  • Family (105): $146.68
  • Self Only (111): $37.13
  • Family (112):$86.95
  • Self Only (111): $34.88
  • Family (112): $81.68

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 1-877-477-3273 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 not career postal employees. Refer to the applicable Guide to Federal Benefits.

Postal Category 1 rates apply to career employees covered by the National Postal Mail Handlers Union (NPMHU), National Association of Letter Carriers (NALC) and Postal Police bargaining units.

Postal Category 2 rates apply to other non-APWU, non-PCES, non-law enforcement Postal Service career employees, including management employees, and employees covered by the National Rural Letter Carriers’ Association bargaining unit.

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Standard and Basic Option Comparison Chart

The following chart offers a comparison of Standard and Basic Option benefits when you use Preferred providers.

PPA = Preferred Provider Allowance  
MAC = Maximum Allowable Charge

Benefit2012 Standard Option
Coverage		2012 Basic Option
Coverage
PHYSICIAN CARE
Inpatient services, including surgery, medical care and outpatient surgery
  • Subject to $350 calendar year deductible.
    15% PPA.
  • $150 copayment per surgeon.
    Nothing for other covered services.
Home and office visits, and outpatient second surgical opinions and consultations
  • $20 office visit copayment for primary care provider.
  • $30 office visit copayment for specialist.
  • $25 office visit copayment for primary care provider.
  • $35 office visit copayment for specialists.
HOSPITAL / FACILITY CARE
Hospital Inpatient: Precertification required
  • $250 per admission copayment for unlimited days.
  • $150 per day up to $750 for unlimited days.
Outpatient Facility Care
  • Subject to $350 calendar year deductible. 15% PPA (except physical, occupational and speech therapy)
  • $75 per day facility copayment.
ACCIDENTAL INJURY / EMERGENCY CARE
Accidental Injury Care: Physician and facility care
  • Nothing for covered charges for services rendered within 72 hours of the accident.
  • $125 copayment — facility.
  • $25 copayment — primary care provider.
  • $35 copayment — specialists.
Medical Emergency Care: Facility care
  • Subject to $350 calendar year deductible. 15% PPA.
  • $125 copayment.
Medical Emergency Care: Physician care
  • $20 office visit copayment for primary care provider.
  • $30 office visit copayment for specialist.
  • $25 copayment — primary care provider.
  • $35 copayment — specialists.
PRESCRIPTION DRUGS
Mail Service Pharmacy
  • Up to a 90-day supply.
    Nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs.
  • Tier 1 (generics): $15 copayment.
  • Tier 2 (Preferred brand-name): $70 copayment.
  • Tier 3 (Non-preferred brand-name): $95 copayment.
  • Not a benefit.
Retail Pharmacy
  • Up to a 90-day supply.
    Nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs when you use a Preferred Pharmacy.
  • Tier 1 (generic): 20% PPA.
  • Tier 2 (Preferred brand-name): 30% PPA.
  • Tier 3 (Non-preferred brand-name): 45% PPA.
  • Tier 4 (specialty drug): 30% PPA

Formulary

Prior Authorization

  • Tier 1 (generic): $10 copayment for a 34-day supply or $30 for a 90-day supply.
  • Tier 2 (Preferred brand-name): $40 copayment for a 34-day supply or $120 for a 90-day supply.
  • Tier 3 (Non-preferred brand-name): 50% PPA ($50 minimum) for a 34-day supply or 50% PPA ($150 minimum) for a 90-day supply.
  • Tier 4 (specialty drug): $50 copayment for a 34-day supply or $150 for a 90-day supply.
Specialty Pharmacy
  • Tier 4 (specialty drug): $80 copayment for up to a 90-day supply. Learn how to obtain prescriptions through our Preferred Specialty Pharmacy.
  • Tier 4 (specialty drug): $40 copayment for a 34-day supply or $120 for a 90-day. Learn how to obtain prescriptions through our Preferred Specialty Pharmacy.
PREVENTIVE CARE
Preventive Screenings and related office visit charge, routine physical exams.
  • Nothing for an annual routine physical and covered preventive screenings.
  • Nothing for an annual routine physical and covered preventive screenings.
DENTAL CARE
Routine Dental Care
  • Benefits paid according to fee schedule in the Service Benefit Plan brochure
  • Your out-of-pocket costs are limited to the MAC
  • $25 copayment.
CHIROPRACTIC CARE AND OSTEOPATHIC MANIPULATIVE TREATMENT
Manipulative Treatment
  • Up to 12 spinal manipulations per year.
  • $20 copayment.
  • Up to 20 spinal manipulations per year.
  • $25 copayment.
OTHER BENEFITS
Catastrophic Benefits
  • 100% payment level begins after you pay $5000 out-of-pocket in eligible coinsurance and copayment expenses.
  • 100% payment level begins after you pay $5000 out-of-pocket in eligible coinsurance and copayment expenses.

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Page last updated: April 04, 2012

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