Blue Cross and Blue Shield Service Benefit Plan.
Frequently Asked Questions.
Welcome to our Frequently Asked Questions section.
This section contains summary information and answers to the most frequently asked questions about the features of the Blue Cross and Blue Shield Service Benefit Plan.
Use the links that follow or scroll down to access the questions and answers.
Please Note: To locate Frequently Asked Questions concerning prescription drug benefits for both the Mail Service and Retail Pharmacy Program click on Pharmacy Programs here or in the Global Menu at the beginning of this page.
Benefits And Claims.
Question: How can I get a claim form?
If you use Preferred network providers, you do not have to submit claims. This is the responsibility of the Preferred provider.
A copy of the medical claim form, the claim forms to use when you receive services and purchase prescription drugs overseas, and the dental claim form are available on this web site in the Contact Us & Forms Section. You can also call your local Blue Cross and Blue Shield Plan at the number on the back of your ID card to get copies of medical, overseas and dental claim forms. Retail pharmacy claim forms are available from the Retail Pharmacy Program by calling this number on the back of your ID card or on the web site under the Pharmacy Programs feature, or under Contact Us & Forms.
Question: I recently received an explanation of benefits about a claim my doctor submitted for surgery. You only paid about half of what she charged. Why didn't you pay for the doctor's total charge?
If you disagree with the local Blue Cross and Blue Shield Plan's payment, you should contact the local Plan in writing within six months of the date of payment and ask the Plan to reconsider the payment. You should include any additional information or explanation of why you disagree with the payment. The local Plan must respond to your reconsideration request, make an additional payment or ask for additional information about the claim within 30 days.
If you still disagree with the Plan's payment, you may ask the US Office of Personnel Management, also known as OPM, to review the claim. OPM will determine if we correctly applied the terms of our contract to your claim.
Question: What types of dental care are covered?
The Service Benefit Plan provides dental benefits under Standard Option and Basic Option.
Covered dental services and the appropriate fee schedule amounts are listed in Section 5(h) of the 2008 Service Benefit Plan brochure and under 2008 Benefits on this web site. If you use a Preferred dentist, you are only responsible for the difference between the fee schedule amount and the Maximum Allowable Charge, also known as MAC. The MAC's are listed in the Preferred Provider directory distributed by your local Blue Cross and Blue Shield Plan. If you use a Non-preferred dentist under Standard Option, you are responsible for the provider's total charge. Basic Option benefits are only available for care by Preferred providers except in certain situations such as emergency care.
Question: What types of preventive care services are paid for under the Service Benefit Plan?
When you use a Preferred network provider, you pay for the related office visit and the following preventive screening tests are covered in full:
• Pap smears.
• Mammograms.
• Stool tests for blood.
• Prostate specific antigen tests.
• Cholesterol tests.
• Sigmoidoscopies.
We also pay for routine physical exams performed by a Preferred physician.
For further information about the services performed by Preferred providers, see Section 5(a) in the 2008 Service Benefit Plan brochure.
Question: I am going to have a baby. How will you pay for my doctor's care and my hospital stay?
If you use a Preferred physician and have Standard Option, we pay covered physician charges in full. Non-preferred (Participating or Non-participating) physician charges are paid subject to the calendar year deductible under Standard Option and at 75 percent of the Plan allowance. When you use a Non-participating physician, you are responsible for the physician's total charge after our payment is made.
Inpatient benefits are paid in full, when you use a Preferred hospital.
If you use a Non-preferred hospital, you are responsible for a $300 per admission co-payment under Standard Option. If the hospital is also a Non-Member facility, you are responsible for a 30 percent coinsurance amount and any difference between our payment and the amount billed, as well.
Under Basic Option, you are responsible for the hospital co-payment of $100 for the inpatient hospital care. Basic Option benefits for professional or physician care are paid in full. Prenatal and postnatal care is paid in full. Basic Option benefits are not available for care performed by Non-preferred providers.
Information coordinated by Paula Spurway, Blue Cross and Blue Shield Association.
Updated December 2007.
Enrollment.
Question: Why are deductions taken from my paycheck before I am updated on the Blue Cross and Blue Shield enrollment system?
The Payroll Office of your employing agency takes deductions for premiums. Enrollment documentation is then forwarded to us for processing - making changes to your current enrollment or adding your enrollment information to our system. The premiums deducted from your paycheck are based on pay periods. In some instances, the Payroll Office processes the premium change before the submission of the enrollment forms to us or before we can process the information. However, the information in our enrollment records will correctly reflect the date of change based on your premium deductions from your paycheck.
Question: How long does it take to receive an ID card after enrollment forms are submitted to my personnel office?
We mail your ID card within 7 to 10 days after we get the enrollment form from your personnel office.
Question: My dependent or child has a different last name than mine. How do I add him/her to my health insurance coverage?
The contract holder, the individual whose name is on the ID card, should contact your local Blue Cross and Blue Shield Plan in writing. In your correspondence, you should include the dependent's name, date of birth, sex, Social Security Number (if available) and his/her relationship to the contract holder. Once this information is received and processed, the dependent will be added to your coverage. You can also go to Customer eService and make this change to your child's last name.
Question: I recently had a baby and need to add her to my coverage. How do I do that?
To change your coverage from self only to family, you, the contract holder, should contact the personnel office of your employing agency. The agency will forward the information about your newborn child to us on an SF 2809. A copy of the SF 2809 is located on the Office of Personnel Management web site at www.opm.gov/forms/html/sf.htm. (Please note: When you choose this link, you are leaving fepblue.org and going to a new web site. We do not endorse this site nor do we make any guarantees about the accuracy and content of the site. Protection of your privacy at the new site is governed by the privacy policy of that site. Therefore, please take time to read the privacy policy of the new site.)
If you already have family coverage, you should contact your local Blue Cross and Blue Shield Plan at the telephone number on the back of your ID card. The local Plan will need to know the baby's name, sex, date of birth and Social Security Number (if available). Or you can go to Customer eService and make the change. (Please note: When you choose this link, you are leaving fepblue.org and going to a new web site. This web site is owned and updated by our Business Partner, The FEP Operations Center, to provide enrollment and claims information about your Service Benefit Plan coverage. Protection of your privacy at the new site is governed by the privacy policy of that site. Therefore, please take time to read the privacy policy of the new site.)
Question: Can anyone change the enrollment information under my health insurance coverage?
No. All changes must be obtained from the contract holder.
Question: I recently got married. How do I add my new spouse to my health insurance coverage?
If you have self only coverage, you should contact the personnel office of your employing agency within 30 days before your marriage or 60 days after your marriage to change your health insurance coverage. The effective date of your spouse's coverage will be the date of marriage if the SF2809 is filed with your employing or personnel office before the date of your marriage and the change to Self and Family coverage is effective prior to the date of marriage. If the SF2809 is filed after the date you got married, the effective date of your new spouse's coverage will be the beginning of the next pay period.
If you currently have family coverage, call your local Blue Cross and Blue Shield Plan at the telephone number on the back of your ID card. The local Plan will need to know your spouse's name, date of birth, sex, Social Security number and the date of the marriage. You can also make the change yourself using Customer eService. (Please note: When you choose this link, you are leaving fepblue.org and going to a new web site. This web site is owned and updated by our Business Partner, The FEP Operations Center, to provide enrollment and claims information about your Service Benefit Plan coverage. Protection of your privacy at the new site is governed by the privacy policy of that site. Therefore, please take time to read the privacy policy of the new site.)
Information coordinated by Paula Spurway, Blue Cross and Blue Shield Association.
Updated December 2007.
Online Security And Confidentiality.
Question: Are my medical records and claims records confidential?
We keep your medical and claims records confidential. Only the following have access to this information:
• The US Office of Personnel Management, also known as OPM, this plan and our subcontractors, such as our prescription drug program vendors for example, when they administer this contract;
• This plan and appropriate third parties, such as other insurance plans and the Office of Workers' Compensations when coordinating benefit payments and subrogating claims;
• Law enforcement officials when investigating and/or prosecuting alleged civil or criminal actions;
• OPM and the General Accounting Office when conducting audits of this plan;
• Individuals involved in bona fide medical research or education that does not disclose your identity; or,
• OPM when reviewing a disputed claim or defending litigation about a claim.
• As part of our administration of prescription drug benefits, we may disclose information about your prescription drug utilization, including the names of prescribing physicians, to any treating physicians or dispensing pharmacies.
Question: Is this web site secure?
Security is based on the level of encryption supported by the Internet browser you use. Browsers that include support for Domestic-Grade encryption provide a greater level of security that those that offer only International-grade encryption.
The benefit and enrollment information on www.fepblue.org is not secure. However, the pages that request information from you and/or require you to submit personal information, such as those related to the mail service pharmacy, requesting an ID card and changing your address, are secure.
Question: How do I know if this or any web site is secure?
A secure web site means that any information you send via the Internet is encrypted so that no one except for the intended recipient can read it.
When you access a web page, if you click your mouse on the Security button, which looks like an open or closed padlock, and is located in the tool bar, at the top of the web page, you will get security or encryption information about that page. There is also a padlock at the bottom left of the screen. When these padlocks are open or unlocked, the page is not secure. A closed or locked padlock means the page is secure or encrypted.
When you use secure parts of the fepblue.org web site, some of the pages are "frames" within the home site. For example, when you reorder prescriptions online from the mail service pharmacy, it looks like the page is not encrypted. However, rest assured that the refill application is encrypted and secure. The "frame," which is fepblue.org, is not secure and this is what the padlocks reflect.
Question: Why do I need a password to access certain features of your web site?
The Health Insurance Portability and Accountability Act (HIPAA) requires confidentiality of person health information. To ensure compliance with HIPAA Regulations for our web site, we had to add a password access to some features, such as our Customer eService feature. Without the use of a password, we would not be able to offer online access to this information.
Information coordinated by Paula Spurway, Blue Cross and Blue Shield Association.
Updated December 2007.
Medicare Prescription Drug Program.
Question: What is the Medicare Prescription Drug Coverage?
Medicare prescription drug coverage is insurance provided by private companies that have been approved by Medicare. Medicare prescription drug coverage is available to everyone with Medicare. This drug coverage may help lower prescription drug costs and help protect against higher costs in the future.
If you chose to join a Medicare prescription drug plan, you will have to pay a monthly premium. All drug plans must provided coverage that is at least as good as standard Medicare prescription drug coverage. Some plans might offer more coverage and additional drugs for higher monthly premiums.
You can get more information about the Medicare prescription drug program at www.medicare.gov or you can call 1.800.MEDICARE (1.800.633.4227). (Please note: When you choose this link, you are leaving fepblue.org and going to a new web site. We do not endorse this site nor do we make any guarantees about the accuracy and content of the site. Protection of your privacy at the new site is governed by the privacy policy of that site. Therefore, please take time to read the privacy policy of the new site.)
If you have limited income and resources, you may qualify for extra help. Most people who qualify for this extra help will pay no premiums, no deductibles and no more than $5 for each prescription. The amount of extra help depends on your income and resources. For more information about extra help, contact the Social Security Administration (SSA) on line at www.ssa.gov or call SSA at 1.800.772.1213. (Please note: When you choose this link, you are leaving fepblue.org and going to a new web site. We do not endorse this site nor do we make any guarantees about the accuracy and content of the site. Protection of your privacy at the new site is governed by the privacy policy of that site. Therefore, please take time to read the privacy policy of the new site.)
Question: I already have prescription drug coverage under my current FEHB health insurance plan. What should I do?
The US Office of Personnel Management (OPM), as are all employers or unions that offer prescription drug coverage, are required to send you information about how your Service Benefit Plan coverage for prescription drugs compares with the Medicare standard prescription drug coverage. This notice is in the inside cover of the Blue Cross and Blue Shield Service Benefit Plan brochure. Please read this notice. It is also a standard part of all brochures for FEHB carriers.
OPM determined that your Service Benefit Plan prescription drug coverage is, on average, expected to pay out as much as the standard Medicare Part D prescription drug coverage will pay for all plan participants and is considered Creditable coverage. Thus you do not need to enroll in Medicare Part D and pay extra for prescription drug benefit coverage. As long as you keep your Service Benefit Plan coverage or other FEHB coverage that is as good as the standard Medicare prescription drug plan, you will not pay a penalty if you decide to enroll in Medicare Part D prescription drug coverage later.
However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare. Remember, if you are an annuitant and you cancel your FEHB coverage, you cannot re-enroll.
Question: If I decide to get Medicare Part D prescription drug coverage, how will it affect my prescription drug benefits?
If you have both Service Benefit Plan and Medicare Part D coverage, the Service Benefit Plan and Medicare will coordinate benefits for covered prescription drug charges. If we are the primary payer, we will provide benefits for your covered prescription drug charges first. If Medicare Part D pays first, we will review your claims for prescription drug costs that are not covered by Medicare Part D and consider them for payment.
For more information about who is primary, see the Primary Payer Chart in Section 9 of the Service Benefit Plan brochure.
Information coordinated by Paula Spurway, Blue Cross and Blue Shield Association.
Updated October 2008.
Question: Why the change from Caremark to Medco?
The Blue Cross and Blue Shield Association (BCBSA) contracts with Pharmacy Benefit Management companies (PBMs) to provide pharmacy services for Service Benefit Plan members: the Mail Service Prescription Drug Program and Retail Pharmacy Program. Periodically, BCBSA surveys the marketplace to determine if the current retail and mail service contracts offer the best value in terms of customer service, drug discounts, network configuration, and dispensing operations. After careful review, BCBSA determined that using Caremark for Retail Pharmacy Services and Medco for Mail Pharmacy Services offered the best value to our members.
Question: What do you mean by best overall value?
In the area of Pharmacy Benefits, best overall value is defined by customer service, network configuration, drug discounts, and dispensing operations. Obtaining best overall value helps to hold down increases in member premiums and prescription co-payments.
Question: How will this change benefit me?
We believe the change in the Mail Service Prescription Drug Program provider enables us to continue to provide our members with a comprehensive health benefits package that includes coverage for prescription drugs at an affordable cost.
Question: Who made the decision to switch vendors?
BCBSA is responsible for the selection and performance of pharmacy vendors. After a competitive procurement, BCBSA determined that a combination of Caremark for Retail Pharmacy Services and Medco for Mail Pharmacy Services offered the most compelling value to the Service Benefit Plan and its members.
Question: When is the change effective?
Effective January 1, 2008, Medco will be the new Mail Service Prescription Drug Program provider replacing Caremark. Caremark will continue to provide Retail Pharmacy Services. For the remainder of 2007, Caremark will continue to provide both Mail Service and Retail Pharmacy Services.
Question: Can I still use my local drugstore for my prescriptions in 2008?
Members can continue to use the local drug store of their choice in 2008. Caremark Inc. will continue to provide Retail Pharmacy services for the Service Benefit Plan.
Question: Will my mail service pharmacy co-payments change?
No. Your co-payments are still $10 for generic drugs and $35 for brand-name drugs.
Question: Will there be any changes to the prior approval program?
No. For a list of drugs requiring prior approval, please visit Pharmacy Programs.
Question: Where do I send specific questions about my mail service benefit?
You can send all correspondence, including inquiries, personal representative authorization forms, etc., to Medco Health Solutions, L.L.C., P.O. Box 30496, Tampa, FL 33630-3496.
Question: How will Medco handle prescriptions that I have on file with Caremark?
Your existing refills at Caremark will be automatically transferred to Medco, except for compound medicines and controlled substances. Members who use the Mail Service Pharmacy Program will receive additional information about prescription transfers in early December 2007. Members who have Mail service prescriptions for compound or controlled substances will need to get a new prescription from their prescribing doctor.
Question: How do I know whether my prescription is for a compound medicine or controlled substance?
If you’re not sure whether your prescription is for a compound medicine or controlled substance, call the mail service Member Services toll-free at 1-800-262-7890. To access TDD service for hearing-impaired members, call 1-800-216-5343.
Question: When should I request refills from Medco’s mail service pharmacy?
You should have at least a 14-day supply of medication on hand before requesting refills. Check your refill dates so that you’ll have plenty of medication when you submit your first refill request to Medco on or after January 1, 2008.
Question: Can I order the rest of my refills from Caremark before the end of the year?
No. The Service Benefit Plan allows you to order prescription refills once 75 percent of your medication has been used. Check your refill dates so you’re sure to have at least a 14-day supply of medication on hand before you can submit refill requests to Medco on January 1, 2008.
Question: What if I have a prescription that has expired or has no refills remaining?
You’ll need to get a new prescription from your doctor for any prescriptions that have expired or that have no refills remaining.
Question: What’s the supply limit for my medication?
You can receive up to a 90-day supply of maintenance medication when you use mail service.
Question: Will my medication(s) look the same?
If you use generic drugs, it’s the generic version that you receive from Medco that will look different than what you’re currently using. That’s because generic drug manufacturers sometimes use different inactive ingredients, such as fillers and dyes. Please be assured that no matter what your generic medication looks like, it will have the same active ingredient as its generic and brand-name counterparts. In addition, Medco uses a different type of medicine bottle than what you’re used to receiving from Caremark.
Question: Will my medication(s) be shipped in the same way as they are now?
It’s possible that your medication will be shipped in different packaging than what you’re used to. However, Medco always uses appropriate temperature-protective packaging for every medication that requires it.
Question: Has the Member Services phone number for mail service changed?
The mail service phone number has not changed. However, the TDD service for hearing-impaired members has changed to 1-800-216-5343.
Question: Whom should I contact after January 1st if I have a question about a prescription that was filled by Caremark in December?
You can call Medco Member Services toll-free at 1-800-262-7890, which is the same number you use today. If Medco is unable to answer your question, your call will be directed to Caremark. To access TDD service for hearing-impaired members, call 1-800-216-5343.
Question: Is there an additional charge for shipping and handling?
There’s no charge for standard shipping. Expedited shipping is available for an additional fee. If, however, expedited shipping is necessary because of a delay caused by Medco, there will be no charge to you.
Question: What information will be transferred from Caremark to Medco?
The following information will be transferred to Medco:
• All open refills, except for compound medicines and controlled substances.
• All prior approvals.
• The last 12 months of prescription history for you and any covered dependents.
Question: Will I continue to receive automated telephone messages about the status of my prescription orders?
Yes.
Question: How do I pay for my mail service prescriptions I get from Medco?
You can pay by check, e-check, money order, or credit card. If you currently use a credit card for your Mail service prescriptions, you’ll need to contact Medco with your credit card information, as this information can’t be transferred from Caremark. Just call Member Services toll-free at 1 800-262-7890. To access TDD service for hearing-impaired members, call 1-800-216-5343.
E-check is another term for electronic funds transfer. When you pay for Mail service prescriptions with e-check, your co-payments are conveniently deducted from your checking account. Plus, there’s a 10-day grace period between the time your order is sent and when the amount is deducted from the assigned checking account. The amount that is being deducted will be included in the prescription information that accompanies your order.
IMPORTANT: If there are insufficient funds at the time Medco submits the funds transfer request, Medco will charge a $10 fee. Your bank also may charge an insufficient funds fee. If your account balance remains insufficient to pay the cost of your mail order after 60 days, your Medco account will be frozen until the balance is paid.
Question: Does the HIPAA (Health Insurance Portability and Accountability Act of 1996) Personal Representative Authorization (PRA) form with Caremark transfer to Medco?
No. Due to HIPAA privacy regulations, your Personal Representative Authorization form on file with Caremark can’t be transferred to Medco. Therefore, you’ll need to submit a new PRA form with Medco. To get a new form, please call Medco Member Services at 1-800-262-7890. To access TDD service for hearing-impaired members, call 1-800-216-5343.
Information prepared by the Blue Cross and Blue Shield Association and Medco.
October 2007.