Blue Cross and Blue Shield Service Benefit Plan.
Welcome To The Blue Cross and Blue Shield Service Benefit Plan For Members Overseas.
We're delighted to have you as a new member and want to provide you with some important information about your health care benefits. Following is an at-a-glance benefit overview of your coverage, so please take a few moments to review it and familiarize yourself with your new benefits. You'll find a complete explanation of your benefits in the 2008 Service Benefit Plan brochure. If you do not have a 2008 brochure, you can call the Blue Cross and Blue Shield Plan in Washington, DC at the number on the back of your ID card to request one.
Please Note: The following items are explanations and definitions of language terms and procedures that define benefits mentioned in the Standard Option and Basic Option Benefits Overview and At-A-Glance chart for overseas members. For an accurate understanding of your benefits, please read and familiarize yourself with these definitions and procedures.
• Calendar Year Deductible is one $300 deductible per member per calendar year, $600 family limit each calendar year. Certain deductibles and coinsurance amounts do not apply to you if Medicare is your primary coverage for medical services, it pays first.
• On limited occasions, such as for certain drugs requiring prior approval, you will need to file a claim for services received from Preferred providers.
• You are responsible for the difference between the amount billed and our payment, even if we pay 100 percent of our plan allowance.
• This is a summary of the Service Benefit Plan benefits. For a complete description, see the 2008 Service Benefit Plan brochure.
Click on any of the section links that follow or scroll down to learn about the 2008 benefits for overseas members.
Overview.
Service Benefit Plan Identification Cards.
By now, you should have received your Blue Cross and Blue Shield Service Benefit Plan identification card or cards. You'll find the most important telephone numbers you need right on the back of your ID card or cards, including customer service, precertification for hospital admissions, prescription drug program and Blue Health Connection telephone numbers. You can use the toll-free numbers when you use the appropriate Country Telephone codes. If you haven't received your card or cards, please notify the Blue Cross and Blue Shield Plan in Washington, DC at 888.999.9862 so they can send your new ID card or cards right away.
Locating A Provider Overseas.
You must call the Overseas Assistance Center toll free at 1.800.699.4337 or e-mail the Center at FEPOverseas@worldaccess.com to verify that your selected provider is in our overseas network. The Center can also help you locate a provider if needed.
You can check out providers overseas in your area by using the Find A Provider feature on the World Access web site. (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, World Access, to provide overseas benefit, provider and other information for our members who live or travel outside the US. 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.
We're glad you chose the Blue Cross and Blue Shield Service Benefit Plan.
We Look Forward To Helping You Stay Healthy.
Overseas Benefits At-A-Glance.
For professional services provided overseas, we provide benefits at the Preferred benefit level under both Standard and Basic Option, using an Overseas Fee Schedule as our Plan Allowance.
Under Standard Option, you are responsible for any difference between our payment and the amount billed, as well as any amounts applied to the deductible, and co-insurance and co-payment amounts. You must also pay for any charges for noncovered services.
Under Basic Option, you pay any difference between our payment and the amount billed, and any co-insurance or co-payment amount. You also pay for noncovered services. The requirement to use Preferred network providers does not apply when you receive care outside the US and Puerto Rico.
Facility care you receive overseas is paid at the Preferred benefit level under both options, after you pay the appropriate co-payment or co-insurance amount. Standard Option members are also responsible for any amounts applied to the calendar year deductible for certain outpatient facility services.
Most providers are under no obligation to file a claim for our members. In these cases, you will need to file a claim form and pay for the care at the time you receive it. If you need to file a claim, a copy of the Overseas Claim Form is available on this web site.
We will provide translation and currency conversion services for your overseas claims.
Preventive Services.
1. Adult Preventive Screenings.
Pap smears, mammograms, stool tests for blood, prostate specific antigen tests, cholesterol tests, sigmoidoscopies and related office visit charge.
Under the Standard Option Benefit:
You pay $15 for each related office visit.
You pay nothing for preventive screening tests, except any difference between our payment and the billed amount.
Under the Basic Option Benefit:
You pay the $20 office visit co-payment for a primary care provider.
You pay the $30 co-payment for specialists.
You pay nothing for preventive screenings billed by your physician, except any difference between our payment and the billed amount.
2. Preventive Exams.
Routine physical exams, including a history and risk assessment, chest X-ray, EKG, urinalysis, CBC, and metabolic and general health panel tests.
Under the Standard Option Benefit:
You pay $15 for the office visit.
You pay nothing for related preventive screening tests, except for any difference between our payment and the amount billed.
Under the Basic Option Benefit:
You pay the $20 office visit co-payment for a primary care provider.
You pay the $30 co-payment for specialists.
You pay nothing for preventive screenings billed by your physician, except any difference between our payment and the amount billed.
3. Preventive Immunizations.
Influenza and Pneumonia immunizations. See the 2008 Service Benefit Plan brochure for timing information.
Under The Standard Option Benefit:
You pay the $15 office visit co-payment.
You pay nothing for immunizations, except for any difference between our payment and the amount billed.
Under The Basic Option Benefit:
You pay the $20 office visit co-payment for a primary care provider.
You pay the $30 co-payment for specialists.
You pay nothing for the services billed by your physician, except any difference between our payment and the amount billed.
4. Preventive Child Care.
Well child care, up to age 22, including routine physical examinations, routine hearing tests, laboratory tests, immunizations, and related office visits.
Under The Standard Option Benefit:
You pay nothing for covered charges, except any difference between the amount paid and the amount billed.
Under The Basic Option Benefit:
You pay nothing for covered charges, except any difference between the amount paid and the amount billed.
5. Preventive Dental Care.
Under The Standard Option Benefit:
You pay the balance up to the Billed charges.
Under The Basic Option Benefit:
You pay the balance up to the Billed charges.
Physician's Care.
1. Physician Inpatient Services.
Inpatient services, including surgical and medical care.
Under The Standard Option Benefit:
You are subject to the $300 calendar year deductible.
You pay the 10% of the Plan allowance.
Under The Basic Option Benefit:
You pay $100 co-payment per surgeon.
You pay nothing for other covered services, except any difference between the amount billed and the amount paid.
2. Physician Outpatient Services.
Outpatient surgery and related diagnostic tests such as X-rays, laboratory tests and machine diagnostic tests. Certain diagnostic cancer tests are paid differently.
Under The Standard Option Benefit:
You are subject to a $300 calendar year deductible.
You pay a 10% of the Plan allowance.
Under The Basic Option Benefit:
You pay $100 co-payment per surgeon.
You pay nothing for other covered services, except any difference between the amount paid and the amount billed.
3. Physician Visits.
Home and office visits, second surgical opinions, outpatient consultations and medical emergency care.
Under The Standard Option Benefit:
You pay the $15 for the visit charge, with no deductible.
Under The Basic Option Benefit:
You pay the $20 office visit co-payment for a primary care provider.
You pay the $30 office visit co-payment for specialists.
4. Physician Outpatient Therapy.
Outpatient physical, occupational and speech therapy, physical therapy.
Under The Standard Option Benefit:
You pay $15 for each visit.
Physical, occupational and speech therapy have a combined limit to 75 visits per person per calendar year.
Under The Basic Option Benefit:
You pay a $20 co-payment for a primary care provider or other health care professional.
You pay a $30 co-payment for specialists.
Physical, Speech and Occupational therapy have a combined limit of 50 visits per person per calendar year.
5. Chiropractic Care.
Spinal manipulations.
Under The Standard Option Benefit:
You pay a $15 co-payment for each visit. Benefits are limited to 12 spinal manipulations per year per person.
Under The Basic Option Benefit:
You pay a $20 co-payment per visit.
Benefits are limited to 20 spinal manipulations per year per person.
Maternity Care.
1. Maternity Care Inpatient Hospital.
Precertification is not required.
Under The Standard Option Benefit:
You pay nothing for covered charges, except any difference between the amount paid and the amount billed.
Under The Basic Option Benefit:
You pay a $100 co-payment for the inpatient hospital care.
2. Maternity Care Physician Care.
Physician care including delivery and pre- and post-natal care.
Under The Standard Option Benefit:
You pay nothing for covered charges, except any difference between the amount paid and the amount billed.
Under The Basic Option Benefit:
You pay nothing for covered pre- and post-natal care and delivery charges.
Hospital charges are subject to the facility co-payments.
Prescription Drugs.
1. Prescription Drugs Mail Service Pharmacy.
You must have an address with a US zip code and the prescribing physician must be licensed in the US to use the Mail Service Pharmacy.
Up to a 90-day supply per prescription or refill.
Under The Standard Option Benefit:
You pay the $10 co-payment for generic drugs.
You pay the $35 co-payment for brand name drugs.
Under The Basic Option Benefit:
This is not a benefit for Basic Option.
2. Prescription Drugs Retail Pharmacy.
Up to a 90-day supply per prescription or refill.
Under The Standard Option Benefit:
You pay the billed charges at the time of purchase, file a claim, then receive 75% of the Plan allowance as reimbursement.
Under The Basic Option Benefit:
You pay the billed charges at the time of purchase, file a claim, then receive 70% of the Plan allowance as reimbursement.
Hospital/Facility Care.
1. Hospital/Facility Inpatient.
Hospital inpatient room and board and other inpatient hospital services. Precertification is not required when you receive care overseas.
Under The Standard Option Benefit:
You have unlimited days.
You pay the $100 per admission co-payment.
Under The Basic Option Benefit:
You have unlimited days.
You pay $100 per day, up to $500.
2. Hospital/Facility Outpatient.
Outpatient surgery.
Under The Standard Option Benefit:
You pay the 15% of the Plan allowance.
Under The Basic Option Benefit:
You pay a $40 co-payment.
3. Hospital/Facility Other Services.
Not including services related to surgery or accidental injury, but including outpatient services for medical emergency care, renal dialysis, radiation therapy and chemotherapy.
Under The Standard Option Benefit:
You are subject to the $300 calendar year deductible.
You pay the 15% of the Plan allowance.
Under The Basic Option Benefit:
You pay a $40 co-payment.
Outpatient physical, occupational and speech therapy.
Under The Standard Option Benefit:
You pay $15 for each visit.
Combined maximum of 75 visits per year.
Under The Basic Option Benefit:
You pay a $40 co-payment.
Combined maximum of 50 visits per person per year.
Laboratory and x-ray services. Certain diagnostic cancer tests are paid differently.
Under The Standard Option Benefit:
You are subject to the $300 calendar year deductible.
You pay 15% of the Plan Allowance.
Under The Basic Option Benefit:
You pay nothing for covered charges.
Accidental Injury.
1. Accidental Injury At A Facility Or Physicians Office Within 72 Hours.
Covered charges in connection with and within 72 hours after an accidental injury at a facility or in a physician's office. See the definition of accidental injury in the 2008 Service Benefit Plan brochure. Includes outpatient medical care, diagnostic tests, and ambulance transportation.
Under The Standard Option Benefit:
You pay nothing for covered charges, except any difference between the amount paid and the amount billed.
Under The Basic Option Benefit:
For emergency room charges, you pay a $50 co-payment.
For care by a primary care provider, you pay a $20 co-payment.
For care by a specialist, you pay a $30 co-payment.
Mental Health And Substance Abuse.
1. Mental Health And Substance Abuse Inpatient Hospital.
Under The Standard Option Benefit:
You pay the $100 per admission co-payment.
You have unlimited days.
Under The Basic Option Benefit:
You pay $100 per day, up to $500.
You have unlimited days.
2. Mental Health And Substance Abuse Outpatient Facility.
Outpatient Facility Care.
Under The Standard Option Benefit:
You are subject to the $300 calendar year deductible.
You pay the 15% of the Plan allowance.
Under The Basic Option Benefit:
You pay a $40 co-payment per day per facility.
3. Mental Health And Substance Abuse Inpatient Professional.
Inpatient Professional Care.
Under The Standard Option Benefit:
You are subject to the $300 calendar year deductible.
You pay the 10% of the Plan allowance.
Under The Basic Option Benefit:
You pay nothing for covered charges.
4. Mental Health And Substance Abuse Outpatient Professional.
Outpatient Professional Care.
Under The Standard Option Benefit:
You pay the $15 co-payment per visit.
Under The Basic Option Benefit:
You pay a $20 co-payment per visit.
Other Services.
1. Other Services Catastrophic Protection.
Catastrophic Protection. Please refer to Section 4 of the 2008 Service Benefit Plan brochure for charges applied to this benefit.
Under The Standard Option Benefit:
100% payment level begins after you pay $4500 out-of-pocket in coinsurance, co-payment and deductible expenses.
Under The Basic Option Benefit:
100% payment level begins after you pay $5000 out-of-pocket in coinsurance, co-payment and deductible expenses.