Straight Talk Brochure
DEAR SERVICE BENEFIT PLAN MEMBERS:
The Blue Cross and Blue Shield Service Benefit Plan has been providing health insurance coverage to federal employees, retirees and their families for more than 50 years.
We believe the right health insurance for you and your family gives you peace of mind knowing you are covered should you need medical care. We try to keep a balance between affordable coverage and comprehensive coverage to meet the needs of our members. With the increasing cost of health care, and changes in the expectations of our members for their health insurance coverage, this balance has become challenging.
We are proud to continue to offer a choice of coverage – Standard and Basic Option – that brings value to our members. We are also proud of our Preferred provider network of almost one million hospitals, physicians, pharmacies and other health care providers in the US, as well as agreements with hospitals overseas. Knowing our members are covered and have access to providers worldwide is important to us.
During the last 50 years, we have all seen many changes in health care and in what is important to us as we go about our daily routines. Exercising, eating healthy and protecting our environment are not new, but they are all more of a priority today. The Blue Cross and Blue Shield Service Benefit Plan gives our members an exercise program with WalkingWorks®, nutritional information for healthy eating with Blue Health Connection, and now a way to help conserve our natural resources.
The 2012 Service Benefit Plan Brochure Is Going Green
We believe going green will help protect and save our environment and is the right thing to do, both in our offices and in how we do business and connect with our members. We’d like to start by reducing paper usage for our printed Blue Cross and Blue Shield Service Benefit Plan brochure. This will in turn reduce costs associated with sending it out each year to our members.
This means you will not be receiving a printed copy of the 2012 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005) in this mailing. However, you can download a copy or visit the US Office of Personnel Management website, www.opm.gov/insure. You can save it on your personal computer , and if you like, just print the pages you need for you and your family. Our goal is not only to provide a more efficient way to get information to you, but to help you reduce the paper clutter at home and do our part to protect the environment.
This newsletter provides information about 2012 benefits, benefit changes and a Standard Option/Basic Option Benefit Comparison Chart. In addition, you can read more about the value of Blue coverage, including wellness programs and preventive care coverage, and information about our online consumer tools that help you take a more active role in your health care decisions and the well-being of your family.
Go Green with Online Explanation of Benefits
Everyone likes to look at the Explanation of Benefits (EOBs) forms to see how we pay for medical care. You can go green, reduce the amount of paper at home and still see how we pay claims by viewing your EOBs online. It’s easy to opt-in to paperless EOBs. Once you select MyBlue Customer eService, just click on the “EOB Mailing Preference” link under the Member Claims and Eligibility feature. The information is the same as on the printed EOB.
Use Preferred Providers and Go Green
Most of you know that when you use Preferred providers, your out-of-pocket expenses are lower and they submit claims for you. Many of our Preferred providers no longer submit paper claims, but submit them electronically to the local Blue Cross and Blue Shield Plan. Now when you use Preferred retail pharmacies, you’re also going green because there’s no paperwork or claim filed. Just present your Service Benefit Plan ID card to get your prescription filled or refilled. Basic Option benefits are not available for prescriptions purchased at non-Preferred retail pharmacies.
When you use non-Preferred providers and pharmacies, you pay more out of pocket and submit a paper claim. But by using Preferred providers, you can save money and also help to save the environment.
Change is sometimes difficult—and going green is no different—but we think it’s the right choice. Have a positive impact on the environment while still having access to the benefit resources needed to make informed decisions about health insurance coverage for your family and to keep track of health care expenses.
Wishing you good health,
The Blue Cross and Blue Shield Service Benefit Plan
2012 BENEFITS AND RATES
It is important to us to provide coverage that brings value to you and your family including:
- A Preferred provider network of almost one million hospitals, physicians, pharmacies and other health care providers
- A free nurse advice line through Blue Health Connection
- Free online tools for you to take charge of your health and health care decisions
- Help when you need it under MyBlue Customer eService
Get More Information
The 2012 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005) provides the contractual description of your benefits. Although we discuss specific benefit changes in this newsletter, we urge you to also read the complete list of benefit changes and clarifications in Section 2 of the 2012 Service Benefit Plan brochure. View and download a copy of the brochure or visit www.opm.gov/insure. Beginning October 17, you can call 1-800-411-BLUE or go online to request a copy of the 2012 brochure be sent to you.
Call our Open Season Information Center at 1-800-411-BLUE (1-800-411-2583) for information about 2012 benefits beginning October 17 through December 31, 2011. The Center is open between 7 am ET and 11 pm ET Monday through Friday, and from 9 am ET to 3 pm ET on Saturday and Sunday. Closed Thanksgiving and Christmas.
Important Prescription Drug Changes For 2012
The benefit changes under Standard Option for 2012 are:
- Under Tier 1 (generic) drug benefits, the 20 percent coinsurance for prescription drugs purchased at a retail pharmacy does not change for 2012 if you do not have Medicare Part B. If you do have Medicare Part B as your primary payer, we have decreased your coinsurance amount to 15 percent for generic drugs in 2012. See Section 9 of the 2012 Service Benefit Plan brochure to determine if Medicare Part B is the primary payer for you.
- Under the mail service prescription drug program, your copayment for Tier 1 (generic) drugs increases from $10 to $15 if you do not have Medicare Part B. The copayment for generic drugs remains unchanged for 2012 if you have Medicare Part B as your primary payer.
- Currently you pay a 30 percent coinsurance for Tier 3 (non-Preferred brand-name) drugs when you purchase your prescription at a retail pharmacy. In 2012, you will pay a 45 percent coinsurance amount for these drugs.
- Under the mail service prescription drug program, you now pay a $70 copayment for Tier 3 (Non-preferred brand-name) drugs. In 2012, you pay a $95 copayment.
- For Tier 4 (specialty) drugs purchased through the specialty prescription drug program, the copayment for 2012 is increased from $70 to $80 when you use a specialty pharmacy. There is no change to the benefits when you purchase Tier 4 drugs at a retail pharmacy. You will still pay a 30 percent coinsurance amount in 2012.
Under Basic Option, there is one prescription drug benefit change for 2012. Basic Option members will be able to use the specialty pharmacy drug program for Tier 4 (specialty) drugs. There is no change to your cost share amount of $40 for a 34-day supply or $120 for a 90-day supply when you use the specialty pharmacy drug program. For specialty drugs purchased at a retail pharmacy, you pay $50 for a 34-day supply or $150 for a 90-day supply.
Other Benefit Changes
- Currently you pay nothing under Basic Option for a sleep study when these diagnostic tests are performed by a Preferred provider. In 2012, you will be responsible for a $75 copayment.
- Under both options, we are increasing the benefit maximum for hearing aids and speech generating devices from $1,000 to $1,250. The $1,250 for hearing aids includes the hearing aid, the dispensing fee, batteries and any necessary supplies.
2012 MyBlue Wellness Incentive
The MyBlue Wellness Incentive for Basic Option members does not change in 2012. Once you complete your 2012 Blue Health Assessment, you will receive a $35 health debit card to be used for qualified medical expenses, up to two $35 cards when two adult members complete the Blue Health Assessment under a family enrollment.
New for 2012, Standard Option members will also receive a $35 health debit card when they complete the Blue Health Assessment. When two adult members under a family contract complete the Blue Health Assessment, you are eligible for two $35 cards.
Also new for 2012, you will be able to add $5 to your health debit card under both options when you complete one online coaching session. You are eligible for up to $15 for completing three sessions. The smoking cessation module is not included in this part of the Wellness Incentive.
Pre-Existing Condition Insurance Program
The Blue Cross and Blue Shield Service Benefit Plan cares about all federal employees, retirees and their families, and believes health insurance is important to your peace of mind. Although the Blue Cross and Blue Shield Service Benefit Plan and other FEHBP carriers cover those who have pre-existing conditions, there are insurance plans that exclude or limit coverage for pre-existing conditions.
If you know someone who has been denied coverage based on a pre-existing condition, then it’s important to know about the Pre-existing Condition Insurance Program (PCIP) created by the Affordable Care Act (ACA). The PCIP makes health insurance available to people who have a problem getting health insurance due to a pre-existing condition and have been without health insurance coverage for at least six months.
The PCIP website, www.pcip.gov, provides information on benefits and premiums for each state. If the PCIP sounds like it may be a health insurance solution for someone you know, go to the PCIP website for more information.
PUT THE POWER OF BLUE TO WORK FOR YOU
Blue gives you the power to create and maintain a healthy lifestyle. It puts resources at your fingertips, giving you the health care-related information you need to take charge of your health.
Talk to a Nurse
How does the Nurse Advice Line add value to your coverage? If you or a family member is ill or injured, or maybe unsure of what to do when faced with a health concern, call Blue Health Connection at the number on the back of your ID card for immediate help. Our registered nurses provide personalized and reliable care advice 24 hours a day, seven days a week. They have an average of more than 15 years’ experience in patient care so you can feel comfortable talking to them. If you prefer communicating through the internet, you can chat with a nurse online in real time by accessing Blue Health Connection.
Diet And Nutrition
Eating a healthy diet isn’t always easy. It can be hard to find recipes or to even know what’s considered a healthy diet for you and your family.
Blue Health Connection is there for you with resources to help you learn more about good nutrition. The Nutrition Wise feature offers weekly articles about diet and nutrition, and includes recipes and information about healthy eating and food safety. In addition, the Relay Clinical Patient Education feature, formerly the Clinical Resource System, has great articles to help you eat right for specific medical conditions, such as diabetes, or manage your weight. Want to talk to someone about your diet concerns? Call Blue Health Connection at 1-888-258-3432 and speak with a registered nurse or go to Blue Health Connection and chat online with one.
Want to add some exercise to your life to improve your health? Walking is an easy way to tone your body, lose some weight and just become more physically active. All you need is a pair of sneakers and a walking plan. Our WalkingWorks Program gives you the encouraging start you need with plans to add walking to your daily routine and set personal walking goals. It can be as easy as parking farther away from a store entrance or taking the stairs at work. You can even make it a family routine by walking around the block every evening.
WalkingWorks gives you a Participant Guide with walking tips and helps to establish your personal walking goal. You can also get a pedometer at no cost to help measure your steps. So go online and check out how WalkingWorks can help you get started.
Blue365 offers exclusive access to information, discounts and savings you can use all year long, making it easier and more affordable to make healthy choices. Leading national companies, in a wide range of categories, have created these special offers and discounts just for Service Benefit plan members. Explore all the choices available to you and your family through Blue365 .
THE VALUE OF WORLDWIDE COVERAGE
Did you know that the Blue Cross and Blue Shield Service Benefit Plan ID card is recognized not only in the US, but worldwide? We even have an Overseas Assistance Center to help you locate providers outside the US when traveling or living overseas.
Overseas Assistance Center
Our Overseas Assistance Center is there when you need it, 24 hours a day, seven days a week. Bilingual operators can help you by:
- Referring you to the nearest Blue Cross and Blue Shield participating hospital or facility
- Talking to your provider to verify your enrollment and coverage
- Making transportation arrangements to another health care setting if necessary
- Helping you locate physicians near where you live or are staying
For assistance, you can:
- Call collect from overseas at 1-804-673-1678 using the appropriate AT&T calling code
- Call toll free at 1-800-699-4337 before you leave to travel or live overseas
- Email the center at FEPOverseas@allianzassistance.com
How To Locate a Provider Overseas
When you know you’ll be traveling or moving overseas, contact the Overseas Assistance Center to help you locate a hospital in our network near where you’ll be staying. Although we don’t have a network of physicians and other health care professionals overseas, the Center can also help you locate a physician if you need medical care.
We’ve Got You Covered
Your Service Benefit Plan coverage works almost the same as when you receive care in the US.
Inpatient Hospital Care: Under both Standard and Basic Options, benefits are paid at the Preferred level. You pay the $250 admission copayment under Standard Option and the $150 per day copayment, up to $750, under Basic Option. Precertification is not required for hospital admissions outside the US.
Outpatient Hospital Care: Benefits under both options are paid at the Preferred level. You pay 15 percent coinsurance under Standard Option after the calendar year deductible is met and a $75 copayment under Basic Option.
Physician Care: Under both Standard and Basic Options, benefits for physician care and care by other covered professional health care providers performed outside the US are paid at the Preferred level using a customary percentage of the billed charge.
If you have questions about overseas benefits or claims, call us toll free at 1-888-999-9862, using the appropriate AT&T calling code if you are calling from abroad.
Preventive care is important at any age. It helps to identify any health concerns or conditions in the early stages of development, making them easier to control. Any related complications will also be easier to treat.
Preventive Care for Adults
Under both Standard and Basic Options, when you use a Preferred provider, you pay nothing for an annual physical exam, or the tests and services usually included as part of it.
Also count on your Service Benefit Plan coverage to pay for cancer screenings when you use a Preferred provider, including colonoscopies to screen for colorectal cancer and mammograms to screen for breast cancer.
Immunizations are a large part of maintaining your good health at any age, although most of us think of immunizations for children. When you use a Preferred provider, you pay nothing for shingles vaccines, HPV vaccines, seasonal flu shots, meningococcal vaccines and tetanus-diphtheria boosters, nor for the related office visit.
Certain immunizations are also free at Preferred pharmacies in our vaccine network. Check with your local pharmacy about participating in this network, or call our Retail Pharmacy Program at 1-800-624-5060 to see which local pharmacies provide immunizations.
When you think of how much a physical exam costs, along with all the individual tests, or how much a mammogram costs, you’re saving a lot of money. That’s the value of Blue – great preventive care with no out-of-pocket costs for you when you use a Preferred provider.
Preventive Care For Children
Your Service Benefit Plan coverage is great for keeping your children healthy from the day they are born. We pay for newborn visits and any routine newborn screening procedures that may be necessary. As they grow, we continue to pay for routine exams, immunizations, laboratory tests and other services essential to your children’s health (following the American Academy of Pediatrics and the Affordable Care Act recommendations and guidelines for children up to the age of 22). You pay nothing under both options for preventive child care when you use a Preferred provider. This means you can keep your children healthy and happy while we pay all the costs.
Preventive care for everyone in your family costs nothing out-of-pocket when you use Preferred providers -- it’s just part of the value Blue brings to your health and well-being.
Want To Keep More Money in Your Pocket?
Your budget and pocketbook can take a hit when you need prescription drugs for a one-time illness or to manage a chronic condition. Using generic drugs offers some savings. Under both Standard and Basic Option, your coinsurance and/or copayment amounts for generic drugs are less than that for brand-name drugs.
If you have Standard Option, when you use a Preferred retailer or the mail service pharmacy, and get your physician to agree to switch your brand-name drugs to generic drugs, you may be able to save even more with the Standard Option Generic Incentive Program. Under this program, we will waive the coinsurance or copayment amount for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs. Your savings can add up when you use this Program — the average savings under the Generic Incentive Program is $30 to $60 per prescription fill or refill. For more about the Generic Incentive Program, see section 5(f) in the 2012 Service Benefit Plan brochure.
MANAGE YOUR HEALTH CARE ONLINE
Manage your enrollment, get help to stop smoking, and take charge of your health and wellness by using our online tools. They’re designed specifically for our members to help you understand and manage your health care benefits. And you can find them all in one location.
Blue Health Assessment
Start on your way to better health by taking our Blue Health Assessment (BHA). Completing the BHA every year is a good idea to measure the impact of any changes or improvements to your lifestyle. If you already took the BHA in 2011, just make any changes to your previous answers and resubmit the BHA. Once complete, you’ll get personalized feedback that identifies potential health risks along with suggestions for actions and talking points to share with your physician.
By completing your BHA in 2012, you also earn the 2012 MyBlue Wellness Incentive. For Standard and Basic Options, you’ll receive a $35 health debit card to be used for qualified medical expenses. Family contracts are eligible to receive two $35 cards when two adult members complete the BHA in 2012.
Online Coaching Sessions
Need help reaching your health and wellness goals? Our 12 online coaching sessions can help by giving you feedback, advice and encouragement as well as the support you need to make positive lifestyle changes. In addition, under both options, you’ll be able to add $5 to your health debit card when you complete online coaching sessions, available on Blue Health Connection (excluding the smoking cessation module). You’re eligible for up to $15 for completing three sessions.
If you’re ready to stop smoking, the Breathe™ online coaching session helps you set goals, track results and ultimately improve your health by not smoking. You also get personalized emails for updates, support and encouragement. After completing Breathe, you may qualify for an additional benefit that waives your individual cost share for certain prescription and over-the-counter smoking cessation medications when you use a Preferred pharmacy.
MyBlue Benefit Statements
Keeping track of your benefits and out-of-pocket expenses during the year can be time consuming. MyBlue Benefit Statements turn a confusing and complicated chore into an easy-to-understand summary of your benefits. MyBlue Quarterly Benefit Statement summarizes your benefits, claims information and out-of-pocket costs for each quarter of the calendar year. MyBlue Annual Benefit Statement summarizes the benefits paid for the previous year.
MyBlue Customer eService
MyBlue Customer eService is like having your own personal customer service representative when you need help managing your enrollment. You can view your Explanation of Benefits online, request duplicate ID cards, change your address, add children after a birth or adoption, and let us know about a marriage or divorce.
Keep in Touch with the Value of Blue
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FSAFEDS IS FOR ANYONE WHO LIKES TO SAVE MONEY
FSAFEDS is the flexible spending account (FSA) program for Federal employees. It allows you to save money for health care and dependent care expenses. Think of it as a savings account that helps you pay for items that typically aren’t covered by your BCBS Service Benefit Plan, the Federal Employees Dental and Vision Insurance Program, or other health insurance coverage. Copayments, prescriptions, and dental and vision expenses are items you likely have to pay for “out of pocket,” and FSAFEDS helps you pay for those expenses. FSAFEDS gives you a tax advantage on the funds you contribute to your account. You make contributions to your FSAFEDS account via payroll deductions, and that money is NEVER taxed, so you pay less in taxes – which means more money in your pocket!
How Do I Save Money?
The money you contribute to your FSAFEDS account is set aside before taxes are deducted, so in most cases you save about 30% on your Federal taxes. The average tax savings for a person earning $50,000 who contributes $2,000 into an FSA account is approximately $600. That means you get $2,000 worth of health care purchasing power PLUS you pay about $600 LESS in Federal taxes.
How Easy Is FSAFEDS?
It’s very easy – anyone can do it! Enrolling, submitting claims, and getting reimbursed are simple and straightforward, and you can keep track of your account online 24/7 – whenever it’s convenient for you. In addition, BCBS and FSAFEDS have partnered to offer a paperless, or “automatic,” claim option called Paperless Reimbursement. In most cases, you’ll have no paperwork to fill out. BCBS and FSAFEDS take care of it all! You pay the copayment for a prescription, and BCBS sends FSAFEDS a claim for your “out-of-pocket” cost electronically. FSAFEDS processes the claim and sends your reimbursement directly to your bank account. It doesn’t get much easier than that!
How Do I Get Started?
First, you estimate what your medical expenses will be in 2012. Think of all the doctor, dentist, and eye care provider office visits you and your family have throughout the year. A comprehensive list of eligible expenses is available at www.FSAFEDS.com. Check out the list today – you’ll be surprised at what items are included! Choose as little as $250 or as much as $5,000.
Once you’ve determined the amount, enroll online during Open Season at www.FSAFEDS.com. The online enrollment takes about 5 minutes to complete. If you prefer, call FSAFEDS toll-free at 1-877-FSAFEDS (1-877-372-3337). Don’t forget to sign up for Paperless Reimbursement with BCBS!
FSAFEDS also offers another exciting feature for families with young children – the Dependent Care FSA. This account allows you to set aside money to pay for your daycare expenses.
Important note: If you are a current FSAFEDS participant, you MUST re-enroll to participate in 2012. FSAFEDS enrollment does not carry over year to year.
This article is provided by FSAFEDS and is for informational purposes only. It is not a benefit under the BCBS Service Benefit Plan nor is it an endorsement of FSAFEDS and the services it offers.
2012 STANDARD AND BASIC OPTION BENEFIT COMPARISON
Remember to always present your Service Benefit Plan ID card when you’re receiving any type of medical or dental care to make sure your ID number is included in the provider’s records.
Certain deductibles, copayments and coinsurance amounts do not apply if Medicare is your primary coverage for medical services. (It pays first).
PPA = Preferred Provider Allowance, MAC = Maximum Allowable Charge
|WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS|
|BENEFIT||2012 STANDARD OPTION COVERAGE*||2012 BASIC OPTION COVERAGE**|
|Mail Service Pharmacy (For information about Tier 4 specialty drug benefits, see Section 5(f) in the 2012 Service Benefit Plan brochure.)||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: $15 copayment for generic drugs if Medicare Part B is not primary, $10 copayment if Medicare Part B is primary.
Tier 2: $70 each for the first 30 Preferred brand-name drug prescription fills or refills, $50 copayment thereafter.
Tier 3: $95 each for the first 30 Non-preferred brand name drug prescription fills or refills, $50 copayment thereafter.
|Not a benefit.|
|Retail Pharmacy Program (For information about Tier 4 specialty drug benefits, see Section 5(f) in the 2012 Service Benefit Plan brochure.)||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 at a Preferred Pharmacy.
Tier 1: 20% PPA for generic drugs if Medicare Part B is not primary, 15% PPA if Medicare Part B is primary.
Tier 2: 30% PPA for Preferred brand-name drugs.
Tier 3: 45% PPA for Non-preferred brand-name drugs.
|Up to a 34-day supply. 90-day supply for 3 copayments.
Tier 1: $10 copayment for generic drugs.
Tier 2: $40 copayment for Preferred brand-name drugs.
Tier 3: 50% coinsurance or $50 minimum for Non-preferred brand name drugs.
|Routine Physical Examination: Adults 22 years of age and older||Nothing||Nothing|
|Routine Physical Examination: Children up to age 22||Nothing||Nothing|
|Preventive Cancer Screenings||Nothing||Nothing|
|ACCIDENTAL INJURY CARE WITHIN 72 HOURS OF THE ACCIDENT|
|Emergency Room||Nothing||$125 copayment.|
|Physician's Office||Nothing||$25 copayment primary care.
$35 copayment specialist.
|Urgent Care Center||Nothing||$50 copayment.|
*When you use Non-preferred facilities and professionals, your out-of-pocket expenses are greater.
**Basic Option does not generally provide benefits for services rendered by Non-preferred providers.
Straight Talk is a publication covering issues and concerns important to Blue Cross and Blue Shield Service Benefit Plan members. It is written by Paula Spurway, Blue Cross and Blue Shield Association, and published by the BCBS Association unless otherwise noted. This is a summary of the Blue Cross and Blue Shield Service Benefit Plan. For a complete description, see the Service Benefit Plan brochure (RI 71-005). Please visit our website for information about your Service Benefit Plan coverage.
Page last updated: October 17, 2012