2009 FEP SERVICE BENEFIT PLAN by IanKnott

VIEWS: 33 PAGES: 2

									2009 FEP SERVICE BENEFIT PLAN

                                                                                              Basic Option
                                                    Standard Option
          Service Benefit Plan                                                         You must see PPO providers
                                                    (PPO providers)
                                                                                           to receive benefits
CALENDAR YEAR DEDUCTIBLE                 $300 per person; $600 per family         No Deductible
                                                                                  $25 copayment per office visit for
PHYSICIAN CARE                           $20 copayment per office visit           primary physician
Diagnostic and treatment services        15% of our allowance                     $30 copayment per office visit for
provided in the office                   (Subject to calendar year deductible)    specialist.
                                                                                  No copayment for lab and x-rays
                                                                                  $25 copayment per office visit for
                                         $20 copayment for office visit
PREVENTIVE CARE                                                                   primary Provider
                                         No out of pocket expenses for covered
Adult routine physical and preventive                                             $30 copayment per office visit for
                                         preventive screenings
screenings                                                                        specialist.
                                         No out-of-pocket expenses for
Well child care(up to 22): routine                                                No out-of-pocket expenses for covered
                                         covered preventative screening
physical exams, routine hearing tests,                                            preventive screening
labs, immunizations and related office
                                         No out-of-pocket expenses for covered
visits                                                                         No out-of-pocket expenses for covered
                                         services
                                                                               services
HOSPITAL CARE
                                         $200 per admission                       $100 per day up to $500 per admission
Inpatient hospital care
                                         15% of our allowance(no deductible for $50 per day per facility(Waived for
Out patient hospital care                surgery)                               covered diagnostic tests)
SURGERY
                                         15% of allowance                         $100 copayment per performing
Inpatient/Outpatient
                                         (Subject to calendar year deductible)    surgeon
Physician Care
                                         No out- of- pocket expenses for
MATERNITY CARE                                                                    $100 copayment per admission
                                         covered services
Inpatient Hospital care
(Pre-certification is not required for
normal delivery
                                                                                  No out- of- pocket expenses for
                                         No out- of- pocket expenses for
Physician care including delivery and                                             covered services
                                         covered services
pre- and post-natal care

                                         $100 per day for ground transport        $100 per day for ground transport
                                         services                                 services
AMBULANCE TRANSPORT
                                         $150 per day for air and sea transport   $150 per day for air and sea transport
                                         services                                 services
EMERGENCY CARE
Accidental Injury                        Nothing for outpatient hospital and      $75 copayment for emergency room
                                         physician services within 72 hours;      care;
                                         regular benefits thereafter              $30 copayment for urgent care

Medical Emergency                        Regular benefits for physician and       Same as for accidental injury
                                         hospital care
                                         (Subject to calendar year deductible)
PRESCRIPTION CARE                        All prescription drugs covered up to a   All prescription drugs covered up to a
                                         90-day supply                            34-day supply
                                                       At Pharmacy
                                         30% coinsurance-Brand Name                     Retail Pharmacy only
                                         20% coinsurance-Generic                           No mail service
                                                                                 $10 copayment-Generic
                                                    Mail Service                 $35 copayment-Formulary Brand
                                         No copayment-Generic(first 4 fills)     Name
                                         $10 copayment-Generic(additional fills) 50% coinsurance Non-Formulary
                                         $65 copayment-Brand Name(first 30       Brand Name($45 minimum)
                                         fills)
                                         $50 copayment-Brand Name(additional
                                         fills)
                                     $20 Copayment per office visit; up to   $25 Copayment per office visit; up to
CHIROPRACTIC CARE                    12 spinal manipulations per calendar    20 spinal manipulations per calendar
                                     year                                    year
                                     $20 Copayment per office visit; $200    $25 copayment per office visit; $100
MENTAL HEALTH AND SUBSTANCE
                                     per admission(prior approval is         per day up to $500 per admission
ABUSE CARE
                                     required)                               (prior approval required)
                                     Limited                                 $20 copayment per office visit
DENTAL CARE
                                     Preventive, fillings and extractions    Preventative care only
                                     Member pay an out-of-pocket
PROTECTION AGAINST
                                     maximum of $5,000 (PPO) or $7,000       Member pay an out-of-pocket
CATASTROPHIC COSTS
                                     (combined PPO/Non-PPO) per              maximum of $5,000 per contract year
(your out-of-pocket maximum)
                                     contract year
Out-of-area coverage                 National and overseas                   National and overseas
24-hour health information service   Blue Health Connection                  Blue Health Connection
Internet Web site                    www.fepblue.org                         www.fepblue.org


To receive the highest level of benefits to which you are entitled, you must use the
Preferred network providers of the Service Benefit Plan PPO. This is a summary of the
features for the year 2009 Blue Cross 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 2009 federal
brochure.

								
To top