Standard Option Benefits Charts-Blue Cross and Blue Shield's Federal Employee Program

2017 Standard Option Benefits Charts

The charts below provide an at-a-glance overview of your benefits under Standard Option.

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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 Standard Option PPO Benefit –
You Pay:
Standard Option Non-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 preventive screenings 35% of the Plan allowance for covered tests
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 immunizations 35% of the Plan allowance

Note: Your deductible and coinsurance amount are waived for influenza vaccines billed by Participating and Non-participating providers
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 35% of the Plan allowance

 Subject to a $350 deductible per Self Only member per calendar year and a $700 deductible for Self Plus One and Self & Family contracts per calendar year.
* When you do not use a Preferred provider, you may be responsible for the difference between the Plan allowance and the billed amount depending on the contracting status of the Non-PPO provider. Emergency admissions to Non-member hospitals are paid at 100% of the Plan allowance after the $350 per admission copayment. 


2017 Professional Provider’s Care

The charts to the right provide an at-a-glance overview of your medical benefits under Standard Option.

2017 Professional Provider’s Care
Services Standard Option PPO Benefit – 
You Pay:
Standard Option Non-PPO Benefit* – You Pay:
Office visits and outpatient consultations

$25 office visit copayment for primary care provider

$35 office visit copayment for specialist 
35% of the Plan allowance

Routine exams and other preventive care services

Nothing for covered services

35% of the Plan allowance

Surgical care

15% of the Plan allowance

35% of the Plan allowance

 Subject to a $350 deductible per Self Only member per calendar year and a $700 deductible for Self Plus One and Self & Family contracts per calendar year.
* When you do not use a Preferred provider, you may be responsible for the difference between the Plan allowance and the billed amount depending on the contracting status of the Non-PPO provider. Emergency admissions to Non-member hospitals are paid at 100% of the Plan allowance after the $350 per admission copayment. 


2017 Pharmacy

If you have Standard Option, you may go to a local Preferred retail pharmacy, or order prescriptions through the Mail Service Pharmacy Program and Specialty Pharmacy Program. You pay nothing for the first four generic prescription fills or refills when you switch from certain brand name drugs to specific generic drugs.

2017 Pharmacy
Services Standard Option PPO Benefit – You Pay:
Mail Service Pharmacy Program
Tier 1 (Generics): $15 copayment
Tier 2 (Preferred brand name): $80 copayment
Tier 3 (Non-preferred brand name): $105 copayment 

Covers 22-90-day supply. Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs.
Retail Pharmacy Program

Tier 1 (Generics): 20% of the Plan allowance
Tier 2 (Preferred brand name): 30% of the Plan allowance
Tier 3 (Non-preferred brand name): 45% of the Plan allowance

Tiers 1, 2 and 3 cover up to a 90-day supply. Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs when you use a Preferred retail pharmacy.

Tier 4 (Preferred specialty drugs): 30% of the Plan allowance
Tier 5 (Non-preferred specialty drugs): 30% of the Plan allowance

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): $35 copayment for up to a 30-day supply; $95 copayment for 31 to 90-day supply 

Tier 5 (Non-preferred specialty drugs): $55 copayment for up to a 30-day supply; $155 copayment for 31 to 90-day supply
 
90-day supply may only be obtained after 3rd fill.

On limited occasions, such as for certain drugs that require prior approval, you will need to file a claim for services received from Preferred providers.


2017 Accidental Injury/Medical Emergency

Under Standard Option, you pay nothing for the treatment of an accidental injury within 72 hours of the injury at any Preferred hospital emergency room, urgent care center or a physician or other healthcare professional's office.

2017 Accidental Injury/Medical Emergency
Services Standard Option PPO Benefit -
You Pay:
Standard Option Non-PPO Benefit* – You Pay:
Accidental injury Nothing for outpatient, hospital and physician services within 72 hours Nothing for covered services

You may be responsible for any difference between the Plan allowance and the billed amount
Medical emergency
Regular benefits for physician and hospital care

15% of the Plan allowance

35% of the Plan allowance
Urgent care $30 copayment for urgent care center 35% of the Plan allowance


Subject to a $350 deductible per Self Only member per calendar year and a $700 deductible for Self Plus One and Self & Family contracts per calendar year.

* When you do not use a Preferred provider, you may be responsible for the difference between the Plan allowance and the billed amount depending on the contracting status of the Non-PPO provider. Emergency admissions to Non-member hospitals are paid at 100% of the Plan allowance after the $350 per admission copayment.

2017 Mental Health and Substance Abuse

Under Standard Option, services for mental health and substance abuse range from inpatient hospital/facility treatment to outpatient professional care. Payments vary based on the use of Preferred providers or Non-preferred providers.

2017 Mental Health and Substance Abuse

Services

Standard Option PPO Benefit -
You Pay:

Standard Option Non-PPO Benefit* – You Pay:

Inpatient Hospital/Facility — Precertification is required $350 per admission copayment for unlimited days $450 per admission copayment for unlimited days, plus 35% of the Plan allowance

Outpatient Hospital/Facility Care 15% of the Plan allowance 35% of the Plan allowance

Inpatient Professional Care Nothing for covered professional visits 35% of the Plan allowance
Outpatient Professional Care $25 per visit copayment 35% of the Plan allowance

 Subject to a $350 deductible per Self Only member per calendar year and a $700 deductible for Self Plus One and Self & Family contracts per calendar year.
* When you do not use a Preferred provider, you may be responsible for the difference between the Plan allowance and the billed amount depending on the contracting status of the Non-PPO provider. Emergency admissions to Non-member hospitals are paid at 100% of the Plan allowance after the $350 per admission copayment. 


2017 Maternity Care

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

2017 Maternity Care

Services

Standard Option PPO Benefit - You Pay:

Standard Option Non-PPO Benefit* - You Pay:

Obstetrical care performed by a physician or nurse midwife, such as prenatal care (including ultrasound, lab and diagnostic tests), delivery, postpartum care You pay nothing for delivery and pre- and postnatal care
35% of the Plan allowance
Inpatient hospital
 
Precertification is not required. Note: you may stay in the hospital for up to 48 hours after a regular delivery and 96 hours after a c-section. We will cover a longer stay if medically necessary; precertification is required for any inpatient stay beyond these time frames.
You pay nothing for delivery and pre- and postnatal care
$450 per admission copayment for unlimited days, plus 35% of the Plan allowance
Outpatient facility care, including outpatient care at birthing facilities You pay nothing for delivery and pre- and postnatal care
35% of the Plan allowance

Subject to a $350 deductible per Self Only member per calendar year and a $700 deductible for Self Plus One and Self & Family contracts per calendar year.

* When you do not use a Preferred provider, you may be responsible for the difference between the Plan allowance and the billed amount depending on the contracting status of the Non-PPO provider. Emergency admissions to Non-member hospitals are paid at 100% of the Plan allowance after the $350 per admission copayment. 


2017 Hospital and Facility Care

The charts to the right provide an at-a-glance overview of your hospital and facility care benefits under Standard Option.

2017 Hospital/Facility Care

Services

Standard Option PPO Benefit – 
You Pay:

Standard Option Non-PPO Benefit* – You Pay:

Hospital Inpatient

Precertification is required 

Unlimited days

$350 per admission copayment
Unlimited days, $450 per admission copayment, plus 35% of the Plan allowance
Outpatient hospital / facility care 15% of the Plan Allowance 35% of the Plan allowance

 Subject to a $350 deductible per Self Only member per calendar year and a $700 deductible for Self Plus One and Self & Family contracts per calendar year.
* When you do not use a Preferred provider, you may be responsible for the difference between the Plan allowance and the billed amount depending on the contracting status of the Non-PPO provider. Emergency admissions to Non-member hospitals are paid at 100% of the Plan allowance after the $350 per admission copayment. 


2017 Other Benefits


2017 Other Benefits

Services

Standard Option PPO Benefit - You Pay:

Standard Option Non-PPO Benefit - You Pay:

Catastrophic Benefits 100% payment level begins after you pay $5,000 (Self Only) or $10,000 (Self Plus One or Self & Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses
100% payment level begins after you pay $7,000 (Self Only) or $14,000 (Self Plus One or Self & Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses
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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