Enrollment

Most Frequently Asked Questions (FAQs)

Learn the answers to commonly asked questions about benefit options, enrolling, finding the right doctor, Medicare and other topics.

Customer Service FAQs

Can I continue coverage after my enrollment terminates?

Employees and/or their family members losing coverage may elect to continue coverage in a Federal Employee Health Benefit (FEHB) Plan or with the local Blue Cross Blue Shield Plan. Coverage ends for employees and eligible family members when the employee separates from Federal employment. Coverage can also end for eligible family members who no longer qualify as dependents. Coverage will be extended for 31 days at no cost after the enrollment terminates for any reason other than voluntary cancellation.

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Who do I call if I have a question about a claim payment?

If you have questions about a claim payment, please call the Blue Cross Blue Shield Plan listed on the Explanation of Benefits (EOB) that you received for your claim. If you do not have the EOB available, you may call the Customer Service phone number listed on the back of your identification card for further assistance. You can also find the contact information for your Local Plan in the Contact Us section of this Web site.

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Do I need a referral to see a specialist?

No, if you use a Preferred provider, you do not need a referral. You can go directly to any of the Preferred primary care physicians or specialists listed in our Provider Directory .

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How can I request an additional or replacement identification card?

To request an additional or replacement ID card visit Customer eService or call your local Blue Cross Blue Shield Plan. To locate the contact information for your Local Plan, please visit the Contact Us section of this Web site.

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Enrollment & Benefits FAQs

How to continue coverage in an FEHB Plan?

Temporary Continuation of Coverage (TCC) allows former employees to continue their healthcare coverage for up to 18 months and eligible family members to continue their healthcare coverage for up to 36 months. Members enrolling in TCC are responsible for both the employee and employer share of the premium, plus an additional 2% administrative fee.

TCC is available to:

  1. Employees and/or their eligible family members when the employee separates from Federal service, except an involuntary separation due to gross misconduct
  2. A change in circumstance that causes an individual to become ineligible to be considered a dependent (e.g., divorce or annulment from employee, unmarried children who reach 26, or children under 22 who marry)

Spouse Equity allows certain former spouses of civil service employees, former employees and annuitants to continue coverage. Unlike TCC, there is no time limit on the length of enrollment. Coverage remains in effect as long as the former spouse is eligible. Former spouses are responsible for both the employee and employer share of the premium with no administrative fee.

Spouse Equity is available to:

  1. Former spouses who do not remarry before age 55
  2. Former spouses who were enrolled as a dependent any time during the 18 months preceding the divorce
  3. Former spouse currently receives, or has future title to receive a portion of the annuity payable to the employee upon retirement

To verify eligibility and enroll, members electing TCC or Spouse Equity must contact their or the employee's employing agency (or OPM for annuitants).

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How to continue coverage with the local Blue Cross Blue Shield Plan?

Conversion coverage allows any employee, annuitant or family member to continue non-FEHB coverage with the local Blue Cross Blue Shield Plan. Unlike TCC or Spouse Equity, any member whose FEHB coverage has terminated for any reason is eligible. Coverage remains in effect as long as the policy is in force.

Members who do not qualify for or decide not to enroll in TCC or Spouse Equity are eligible for conversion. Members whose TCC or Spouse Equity coverage ends may also apply for conversion coverage offered by the terminated member's local Blue Cross Blue Shield Plan.

Benefits and rates for conversion coverage will differ from those under the FEHB Program. Benefits which may have been provided under the FEHB coverage are not guaranteed and do not in any way affect the benefits available to the member under conversion coverage. However, the local Blue Cross and Blue Shield Plan will not ask you questions about your health and will not impose a waiting period for pre-existing conditions.

For more information on conversion coverage offered by your local Blue Cross Blue Shield Plan, please contact the customer service number on the back of your BlueCross BlueShield Federal Employee Program identification card.

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What is the difference between Standard Option and Basic Option?

While both Options offer comprehensive benefits for you and your family, they are structured differently to complement different healthcare needs. Under Basic Option, you use Preferred providers to provide all the medical care you and your family need, and there is no deductible. Standard Option provides benefits regardless of whether you use a Preferred or Non-participating provider; however, your out-of-pocket expenses will probably be lower if you choose a Preferred provider. For more information about the differences between the two Options, please visit the Compare Benefits section of this Web site or consult the Service Benefit Plan brochure or use askblue.fepblue.org to learn more about the differences between Basic Option and Standard Option.

Whether you decide to enroll in Standard Option or Basic Option, please be sure to use the appropriate enrollment code:

 SelfSelf and Family
Standard Option104105
Basic Option111112

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Does the Service Benefit Plan offer dental benefits?

Yes. Both Standard Option and Basic Option offer some level of dental benefits. Basic Option provides preventive dental care while Standard Option provides additional routine services. Additional information is available in the Basic Option Dental Benefits and Standard Option Dental Benefits sections of this Web site or consult the Service Benefit Plan brochure for more details.

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What is Temporary Continuation of Coverage (TCC) and what are the requirements to enroll under the TCC provisions of the Federal Employees Health Benefits (FEHB) law?

Temporary Continuation of Coverage (TCC) is available to:

  1. Employees who lose their FEHBP coverage because they leave their federal jobs; except in involuntary separations due to misconducts
  2. Children who lose their FEHBP family member status because they become age 26 or marry
  3. Former spouses who lose their FEHBP family member status because of divorce or annulment

TCC allows former employees to continue their healthcare coverage for up to 18 months and former family members (children and former spouses) to continue healthcare coverage for up to 36 months. TCC enrollees must pay the full premium for the plan they select (that is, both the employee and Government shares of the premium) plus a 2 percent administrative charge. For more specific information about TCC, please contact your employing office's health benefits officer.

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When is Open Season?

The US Office of Personnel Management (OPM) holds Open Season each year from the Monday of the second full workweek in November through the Monday of the second full workweek in December. Your Open Season election generally will take effect the following January. Please contact your employing office's health benefits officer for additional information.

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Where can I call to get benefit information about the Service Benefit Plan?

During Open Season, you may call our Open Season Information Center at 1-800-411-BLUE. You may also contact your local Blue Cross Blue Shield Plan year-round for information about the Service Benefit Plan. To locate the contact information for your Local Plan, please visit the Contact Us section of this Web site. For current members, you can also find the phone number on the back of your identification card.

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Does Standard Option or Basic Option provide coverage if I am overseas?

Yes, the Service Benefit Plan provides overseas coverage for you and your covered family members through our 24-hour Worldwide Assistance Center. Please keep in mind that many overseas providers require payment upfront and there will be differences regarding coverage and reimbursement between coverage under Standard Option and Basic Option . For more information, please visit the Standard Option and Basic Option Overseas Benefits sections of this Web site or consult the Service Benefit Plan brochure.

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General Pharmacy FAQs

What is the formulary list?

The formulary list is a list of medicines that are considered the preferred treatment for a patient's condition and that can be used as a guide for a doctor when prescribing medicine. The formulary list was developed by an independent panel of doctors and pharmacists who worked with the Service Benefit Plan to ensure that the medicines listed were the most clinically appropriate and cost-effective medicines. While your prescription medicine program is not limited to the drugs on the formulary list, using formulary medicines may reduce your out-of-pocket expense. You can find a link to the formulary list here.

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What are the benefits of a formulary list?

The formulary list:

  • Promotes use of prescriptions that could improve patient care and contain costs
  • Empowers the member to be an educated healthcare consumer
  • May encourage members to discuss their prescription medicine treatment with their physicians
  • Aids the physician in making informed decisions based on appropriate clinical and prescribing guidelines

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What if I want to take a medicine that is not on the formulary list?

Medicines that are not listed on the formulary are considered Non-Preferred medicines. You may still receive benefits if you choose a Non-Preferred medicine; however, your out-of-pocket expenses will be greater.

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Where can I obtain a list of prescription drugs that require prior approval?

You can visit Caremark’s website for a list of prescription drugs that require prior approval, along with an explanation of the prior approval criteria, forms, and rationale. Your physician can also provide you with more information concerning prior approvals.

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Are generic medications as safe and effective as brand-name medications?

There are some myths about generic medications. Some people believe that generic medications are not as safe as their brand-name counterparts. Others believe that they are more likely to cause side effects than brand-name medications. The fact is that the FDA mandates that all FDA-approved medications, brand name and generic, must be safe and effective. In order to get FDA approval, the generic medication must contain the same active ingredients as the brand-name product and must meet the same strict quality standards. The generic medication must also be the equivalent in strength and dosage to the original brand-name medication.

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Why are generic drugs less expensive than brand-name drugs?

It's expensive to create a new brand name drug and market it to the public. Generic drug manufacturers do not have those expenses, since they don't pay for the research that led to the discovery of the new drug. Therefore, the medications they produce can cost significantly less for the exact same ingredients, strengths and doses. Those savings are usually passed on to you through lower out-of-pocket costs when generics are selected. Generic medications could lower your out-of-pocket costs by up to 60 percent over the cost of a brand-name medication.

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How can I find out if there is a generic medication for the brand-name drug that I am taking?

There are two ways to find out if the brand-name drug you are taking is available in generic form. You can click on Pharmacy and then follow the prompts to the Standard Option mail or retail pharmacy, or Basic Option retail pharmacy and you will be taken to the CVS Caremark login page. If you do not have a login ID and password, follow the prompts to create one. Once you have logged in, follow the prompts to enter drug information. You can also contact the mail service and retail prescription programs at the following toll- free numbers and a customer service representative will assist you.

  • Retail 1-800-624-5060
  • Mail Service 1-800-262-7890
  • Specialty 1-888-346-3731

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How do I find a participating pharmacy?

You can visit our online pharmacy finder or contact the Retail Pharmacy Program 1-800-624-5060 for the most up-to-date listing in your area.

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I have Standard Option. Based on the benefits, is it more beneficial for me to go to my retail pharmacy or through the Mail Service Prescription Drug Program?

This is a decision that is entirely up to you. In order to make an informed decision, you will need to determine the Service Benefit Plan Preferred retail price and your 30% contribution to the cost of the medication. You can then compare the retail coinsurance cost to the flat copayment of $70 for first 30 brand-name prescriptions filled (and/or refills ordered) per calendar year, $50 per brand-name prescription/refill thereafter, and $15.00 for generic medicines if you use the Mail Service Prescription program.

To make sure you are getting the best value check the cost of your prescription drugs on our retail pharmacy site , by using the "price quote" feature on the retail program website. If you do not have a login ID and password, follow the prompts to create one. Once you have logged in, click on 'Check Drug Cost' on the left hand side of the page. On the Check Drug Cost page, select the participant's name and enter the name of the drug. Click the 'Search' button. Select the appropriate strength and click 'Continue'. On the next page, enter the quantity your doctor has prescribed and select a retail pharmacy. Click 'Get Results'. The next page will provide estimated copayment amounts for the brand and generic forms of the drug, if available, for both retail and mail order.

You can also contact the Caremark Customer Care Unit at the following toll- free numbers and ask a customer service representative to assist you.

  • Retail 1-800-624-5060
  • Mail Service 1-800-262-7890

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I have Standard Option. Can you transfer my prescription from the Mail Service Prescription Drug Program to my local pharmacy?

Yes. A valid prescription can be transferred from the Mail Service Prescription Drug Program to your participating retail pharmacy. However, once the prescription is transferred, a new prescription will be needed before the Mail Service Prescription Drug Program can dispense the medicine again.

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I have Basic Option. How do I know what copayment I'll pay for the medicine I'm currently taking?

Under Basic Option, there are three copayment levels. The copayment levels are:

  • $10 for generics
  • $40 for Preferred brand name medicines
  • 50% coinsurance for Non-Preferred brand name drugs, with a minimum copayment of $50
  • $50 copay (34DS), $150 copay (90DS) for Specialty medicines (Preferred Retail Pharmacy), or $40 copay (34DS), $120 copay (90DS) for Specialty medicines (Specialty Drug Pharmacy)

You can find information on which level your medicines are in and the associated cost by visiting the "price quote" feature on the Retail Program Web site where you will be directed to Caremark.com. If you do not have a login ID and password, follow the prompts to create one. Once you have logged in, click on 'Check Drug Cost' on the left hand side of the page. On the Check Drug Cost page, select the participant's name and enter the name of the drug. Click the 'Search' button. Select the appropriate strength and click 'Continue'. On the next page, enter the quantity your doctor has prescribed and select a retail pharmacy. Click 'Get Results'. The next page will provide estimated copayment amounts for the brand and generic forms of the drug, if available, for both retail and mail order.

You may also contact the Retail Prescription Program at 1-800-624-5060 and a customer service representative will assist you.

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I have Basic Option. Why are there different copayment levels for different drugs?

The cost of medicines varies greatly, even though there may be different medicines available to treat the same condition. Generic medicines typically offer the most savings and have the lowest copayment. Brand name medicines generally are more expensive and there can be many different brand name medicines at various cost levels available to treat the same condition.

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I have Basic Option. Can I get my medicine from an out-of-network pharmacy?

If you obtain your medicine from an out-of-network pharmacy, you will be responsible for 100 percent of the medicine's cost.

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Overseas FAQs

Am I covered overseas?

Yes, your Service Benefit Plan coverage protects you around the world. Benefits for covered services under both Standard and Basic Option are paid at the Preferred level. Professional care is paid at the Preferred benefit level based on the overseas fee schedule. You may be responsible for differences between our payment and the provider charge since overseas providers do not agree to accept our payment as payment in full in all cases. See Section 5(i) in the Service Benefit Plan brochure for more information about how benefits are paid for care performed overseas.

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Do I have benefits for evacuation?

Our Overseas Assistance Center offers emergency evacuation services to the nearest facility to adequately treat your condition only. We do not consider benefits to transport you to the United States unless that is the closest facility that can provide adequate treatment. We do not consider benefits for evacuation in the event of a natural disaster.

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Does Caremark send medication overseas?

If you have Standard Option, your coverage includes our Mail Service Pharmacy benefit. You can order prescription drugs through the Mail Service Pharmacy if your address has a US zip code, and the prescribing physician is licensed in the US. We suggest you contact Caremark directly to ensure your specific medication can be mailed overseas. You may contact them by calling 1-800-262-7890 or by writing to them at Caremark, P.O. Box 52080, Phoenix, AZ 85072-2080. You may be eligible for an extended filling of the prescription from Caremark while overseas or before going overseas, so you may also want to discuss this with Caremark. Please note this will require a prescription from your doctor for 12 months and is not applicable for controlled substances.

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What do I do if I need to find a provider?

You can access a listing of overseas providers on our overseas assistance web site in the Provider Directory. You can also call our Overseas Assistance Center collect at 1-804-673-1678 or email the Center at FEPOverseas@mondialusa.com.

We do have a network of participating hospitals overseas. Although we do not have a network of physicians and other health care professionals, the Center can also help you locate a physician.

You do not have to use the providers in our network overseas.

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How do I file a claim?

You can find our Overseas Medical Claim Form and the Retail Prescription Drug Overseas Claim Form in the forms library , or you can request that we send you some claim forms.

If you access a claim form on our web site, you can enter the information directly on the claim form; print a copy to send to us.

In most situations, you will need to pay the provider up front and submit the medical charge(s) to us at Mail Room Administrator, FEP Overseas Claims, P.O. Box 14113, Lexington, KY 40512-4113. Effective 01/01/10, you may also fax your overseas claims to 1-888-650-6525 or 1-410-781-7637 (See below for instructions on how to fax claims). Payment for covered services will be sent to you. If the provider does not require payment at the time the care is performed, you may request we pay the provider directly by filling out 6B of the claim form and leaving 6 and 6A blank. Send the claim form along with the itemized bills from the provider to the address or fax number listed above and on the back of the form. Box 4 must include the diagnosis or reason for the services in order to process your claim.

To file a claim for covered drugs and supplies you purchase from pharmacies outside of the United States and Puerto Rico, send a completed Retail Prescription Drug Overseas Claim Form, along with itemized pharmacy receipts or bills to Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program P.O. Box 52057, Phoenix, AZ 85072-2057.

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How do I fax overseas claims to a toll free number?

There is a two step process for faxing claims to our toll free number in the United States from most overseas locations.

  1. The international caller first dials the AT&T Direct Access Code for the country from which they are faxing.
  2. The caller will hear a recording asking them to enter the U.S. toll free number they want to fax. A "1" is not required before the toll free number.

AT&T has a dialing guide and a list of access codes available at
http://www.business.att.com/bt/dial_guide.jsp

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What is an itemized bill?

An itemized bill must include:

  1. Name of the patient;
  2. Name and address of person or firm providing the service or supply;
  3. Date for each service or supply;
  4. Type or description for each service or supply;
  5. The diagnosis for each service or supply.

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How do I get paid?

If you would like a wire transfer or payment in a foreign currency for your medical claims, be sure to follow the directions, and fill out boxes 6 and 6A on the Overseas Medical Claim Form. Please note the wire transfer or a check in the local currency may take longer than a paper check in US dollars. If you do not request these options payment will be made by check in US dollars.

Payments for covered drugs and supplies you purchase from pharmacies outside of the United States and Puerto Rico will only be made by check in US dollars.

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What if my claims are in a different language and currency?

That is not a problem. When your claim is received, we will do the translation and currency conversion. The currency conversion is based on the date of service or the date you paid the bill, if you provide that information. For the most accurate currency conversion, please provide us a receipt with the date the bill was paid, the amount you paid and the exchange rate used if available.

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What if I have Medicare or supplemental travel insurance?

Medicare does not provide benefits for care performed outside the US. Therefore, if you have Medicare as your primary insurer and services were rendered outside the United States and US Territories, there is no need to send your claim first to Medicare. Please send the completed claim form and itemized bills to us. We will consider benefits at 100% of our plan allowance.

If you choose a supplemental insurance plan to cover you while overseas, we will remain the primary insurance. This means that you will submit any claims for medical care to us first.

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What types of providers are in your international provider network?

The provider network consists mainly of hospitals. Information regarding providers is available by contacting our Overseas Assistance Center directly at 1-800-699-4337 if you are in the US, collect at 1-804-673-1678, or via email at FEPOverseas@mondialusa.com.

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What happens if a member needs inpatient care?

If the member is hospitalized at a participating provider, our Overseas Assistance Center will arrange for cashless access. This means you will not have to pay upon admission to the hospital. At the time discharge, you need only pay the out-of-pocket expenses, such as deductible, coinsurance and copayment amounts. If you are hospitalized at a non-participating hospital, our Overseas Assistance Center will try to negotiate this same cashless access but may not get the hospital to agree. In this case, you may be required to pay a deposit at the time of admission and all charges upon discharge. To request help with this type of care, contact our Overseas Assistance Center directly at 1-800-699-4337 if you are in the US or collect at
1-804-673-1678, if you are calling from outside the US.

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Is pre-certification required when a member is hospitalized?

No, precertification is not required for inpatient services provided outside the US.

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Page last updated: January 03, 2012

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