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.
Pages to are hidden for
"2009 FEP SERVICE BENEFIT PLAN"Please download to view full document