Basic Option Benefits Tables-Blue Cross and Blue Shield's Federal Employee Program

2017 Basic Option Benefits Charts

The charts below provide an at-a-glance overview of your benefits under Basic Option. Under Basic Option, you must use Preferred providers for all the medical care you receive. Benefits for care performed by Non-preferred providers are only available in certain situations, such as emergency care.

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2017 Preventive Care

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 treat. Any related complications may also be easier to treat.

2017 Preventive Care
Services Basic Option PPO Benefit* - You Pay
Preventive care services for adults age 22 and older including the preventive services recommended by the U.S. Preventive Services Taskforce. Services include but are not limited to: 
  • Visits or exams for preventive care, including a history and risk assessment, chest X-ray, EKG, urinalysis, CBC, fasting lipid profile, cholesterol tests and metabolic and general health panel tests
  • Preventive screenings: Pap smears, mammograms, colorectal cancer tests, prostate cancer tests, STD screenings, genetic counseling in certain situations, and related office visits
Nothing for covered services
Routine immunizations for adults age 22 and older [as licensed by the U.S. Food and Drug Administration (FDA)], limited to:
  • Hepatitis (Types A and B) 
  • Herpes Zoster (shingles)^
  • Human Papillomavirus (HPV)^
  • Influenza (flu)^
  • Measles, Mumps, Rubella
  • Meningococcal^
  • Pneumococcal^ 
  • Tetanus-diphtheria, pertussis booster (one every 10 years)
  • Varicella
^Many Preferred retail pharmacies participate in our vaccine network. Review pharmacy benefits for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Nothing for covered services
Preventive care services for children up to age 22, including preventive services recommended under the Affordable Care Act and the American Academy of Pediatrics. These services include but are not limited to visits or exams for preventive care, routine hearing and vision screenings, laboratory tests, immunizations, and nutritional counseling. Nothing for covered services

Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.


2017 Professional Provider’s Care

Almost one million strong, our network of Preferred providers includes surgical experts and specialists.

2017 Professional Provider's Care
Services Basic Option PPO Benefit* - You Pay
Office visits and outpatient consultations $30 copayment per visit for primary care provider
             
$40 copayment per visit  for specialists
Routine exams and other preventive care services Nothing for covered services
Surgical care $150 copayment per performing surgeon in an office setting;

$200 copayment per performing surgeon in other settings

* Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.


2017 Pharmacy

Basic Option members must use a Preferred retail pharmacy or the Specialty Pharmacy Program. Basic Option benefits are not available when you use Non-preferred pharmacies.

2017 Pharmacy
Benefit Basic Option PPO Benefit – You Pay
Mail Service Pharmacy Program

Available to members with Medicare Part B primary only

Retail Pharmacy Program

Tier 1 (Generic):  $10 copayment
Tier 2 (Preferred brand name*): $50 copayment
Tier 3 (Non-preferred brand name*): 60% of the Plan allowance with a $65 minimum

Tiers 1, 2 and 3 cover up to a 30-day supply, or up to 90-day supply for additional copayments

Tier 4 (Preferred specialty drugs*): $65 copayment
(30-day supply)
Tier 5 (Non-preferred specialty drugs*): $90 copayment (30-day supply) 

Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.

Specialty Pharmacy Program Tier 4 (Preferred specialty drugs*): $55 copayment
(30-day supply); $165 copayment (31 to 90-day supply)

Tier 5 (Non-preferred specialty drugs*): $80 copayment (30-day supply); $240 copayment (31 to 90-day supply) 
90-day supply may only be obtained after 3rd fill

* Your costs for prescription drugs are lower if you have Medicare Part B primary coverage.


2017 Accidental Injury / Medical Emergency

Basic Option members are encouraged to seek care from Preferred providers in cases of accidental injury or medical emergency.

However, if you need care immediately and cannot access a Preferred provider, we will provide benefits for the initial treatment  provided in the emergency room of any hospital — even if the hospital is not a Preferred facility.

2017 Accidental Injury / Medical Emergency
Services Basic Option PPO Benefit* – You Pay:
Accidental injury or medical emergency $125 copayment for emergency room care 
             
$35 copayment for urgent care center 

Regular benefits for physician care

* Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.


2017 Mental Health and Substance Abuse

Under Basic Option, services for mental health and substance abuse range from inpatient hospital/facility treatment to outpatient professional care. Basic Option members must use Preferred providers.  

2017 Mental Health and Substance Abuse
Services Basic Option PPO Benefit – You Pay:
Inpatient Hospital/Facility 

Precertification is required
$175 copayment per day up to $875 per admission for unlimited days
Outpatient Hospital/Facility Care $30 copayment per day per facility
Inpatient Professional Care Nothing for covered professional visits
Outpatient Professional Care $30 per visit copayment

2017 Maternity

A variety of benefits are available for a healthy pregnancy — from prenatal to postpartum.

2017 Maternity
Services Basic Option PPO Benefit* – You Pay:
Obstetrical care performed by a physcian or nurse midwife, such as prenatal care (including ultrasound, lab, diagnostic tests), delivery, postpartum care  Nothing for covered services
Inpatient hospital

Precertification is not required for routine delivery.
Note: You may stay in the hospital for up to 48 hours after a regular delivery and 96 hours after C-section. We will cover a longer stay if medically necessary; precertification is required for any inpatient stay beyond these timeframes.

 $175 per inpatient admission copayment
Outpatient facility care, including outpatient care at birth facilities  Nothing for covered services

* Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.


2017 Hospital and Facility Care

The chart to the right provides an at-a-glance overview of your hospital and facility care benefits under Basic Option.
2017 Hospital/Facility Care
Services Basic Option PPO Benefit*– You Pay:
Hospital Inpatient 

Precertification is required
$175 copayment per day up to $875 per admission for unlimited days
Outpatient facility care/facility care $100 per day per facility copayment

* Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.


2017 Other Benefits


2017 Other Benefits
Services Basic Option PPO Benefit* – You Pay:
Catastrophic Benefits Preferred Provider Services: Your out-of-pocket maximum is $5,500 for Self Only and $11,000 for Self Plus One and Self & Family contracts
* Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.
Certain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first).

This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Plan’s federal brochure (RI 71-005). All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure.

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