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Compare Benefit Options

The Service Benefit Plan offers two types of coverage: Standard Option and Basic Option. Standard Option gives you the freedom to receive covered services from both Preferred and Non-preferred providers. Basic Option members must receive care performed by Preferred providers, except in certain situations like emergency care. Standard Option also has a calendar year deductible, while Basic Option does not. Most care under Basic Option is subject to a copayment amount.

2013 Premiums — Your Share

Outlined below is a summary of the Service Benefit Plan benefits. Refer to the Service Benefit Plan brochure (RI 71-005) for comprehensive benefit information for both options. All benefits are subject to the definitions, limitations and exclusions set forth in the 2013 Benefit Plan brochure.

If you are a tribal employee, please note that rates may vary for you. Contact your Human Resources representative for additional information or to inquire about enrolling.

2013 Standard Option2013 Basic Option
Non-Postal Premium
Biweekly
  • Self Only (104): $85.91
  • Family (105): $200.14
  • Self Only (111): $59.07
  • Family (112): $138.32
Non-Postal Premium
Monthly
  • Self Only (104): $186.14
  • Family (105):$433.63
  • Self Only (111):$127.99
  • Family (112):$299.70
 Category 1Category 2Category 1Category 2
Postal Premium
Biweekly
  • Self Only (104): $64.71
  • Family (105): $152.92
  • Self Only (104): $70.01
  • Family (105): $164.73
  • Self Only (111): $38.99
  • Family (112):$91.29
  • Self Only (111): $44.31
  • Family (112): $103.74

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, refer to the Guide to Federal Benefits for that category or contact the agency that maintains your health benefits enrollment. Career non-law enforcement employees may also refer to the Guide to Federal Benefits for United States Postal Service Employees, RI 70-2, to determine their rates. Different rates apply and a special Guide is published for Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-21N). For additional assistance, Postal Service employees can call the Human Resources Shared Service Center at 1.877.477.3273 and select option 5. Postal rates do not apply to non-career postal employees, postal retirees or associate members of any postal employee organization who are non-career postal employees. Refer to the applicable Guide to Federal Benefits.

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Standard Option and Basic Option Comparison Chart

The following chart offers a comparison of Standard and Basic Option benefits when you use Preferred providers.

PPA = Preferred Provider Allowance  
MAC = Maximum Allowable Charge

 

Benefit2013 Standard Option
Coverage		2013 Basic Option
Coverage
PHYSICIAN CARE
Inpatient services, including surgery, medical care and outpatient surgery
  • Subject to $350 calendar year deductible.
    15% PPA.
  • $150 copayment per surgeon.
    Nothing for other covered services.
Home and office visits, and outpatient second surgical opinions and consultations
  • $20 office visit copayment for primary care provider.
  • $30 office visit copayment for specialist.
  • $25 office visit copayment for primary care provider.
  • $35 office visit copayment for specialist.
HOSPITAL / FACILITY CARE
Hospital Inpatient: Precertification required
  • $250 per admission copayment for unlimited days.
  • $150 per day up to $750 for unlimited days.
Outpatient Facility Care
  • Subject to $350 calendar year deductible. 15% PPA (except physical, occupational and speech therapy)
  • $100 per day facility copayment.
ACCIDENTAL INJURY / EMERGENCY CARE
Accidental Injury Care: Physician and facility care
  • Nothing for covered charges for services rendered within 72 hours of the accident.
  • $125 copayment — emergency room.
  • $50 copayment — urgent care center.
  • $25 copayment — primary care provider.
  • $35 copayment — specialist.
Medical Emergency Care: Facility care
  • Subject to $350 calendar year deductible. 15% PPA.
  • $40 copayment per visit for urgent care center.
  • $125 copayment per visit for emergency room.
  • $50 copayment per visit for urgent care center.
Medical Emergency Care: Physician care
  • $20 office visit copayment for primary care provider.
  • $30 office visit copayment for specialist.
  • $25 copayment for primary care provider.
  • $35 copayment for specialist.
PRESCRIPTION DRUGS
Mail Service Pharmacy
  • Up to a 90-day supply.
    Nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs.
  • Tier 1 (generics): $15 copayment.
  • Tier 2 (Preferred brand-name): $70 copayment.
  • Tier 3 (Non-preferred brand-name): $95 copayment.
  • Not a benefit.
Retail Pharmacy
  • Up to a 90-day supply.
    Nothing for the first four prescription fills or refills when you switch from certain brand-name drugs to specific generic drugs when you use a Preferred Pharmacy.
  • Tier 1 (generic): 20% PPA.
  • Tier 2 (Preferred brand-name): 30% PPA.
  • Tier 3 (Non-preferred brand-name): 45% PPA.
  • Tier 4 (specialty drug): 30% PPA

Formulary

Prior Authorization

Up to a 34-day supply. 90-day supply for 3 copayments.

  • Tier 1 (generic): $10 copayment.
  • Tier 2 (Preferred brand-name): $40 copayment.
  • Tier 3 (Non-preferred brand-name): 50% coinsurance with $50 minimum.
  • Tier 4 (specialty drug): $50 copayment for a 34-day supply or $150 for a 90-day supply.
Specialty Pharmacy
  • Tier 4 (specialty drug): $80 copayment for up to a 90-day supply. Learn how to obtain prescriptions through our Preferred Specialty Pharmacy.
  • Tier 4 (specialty drug): $40 copayment for a 34-day supply or $120 for a 90-day. Learn how to obtain prescriptions through our Preferred Specialty Pharmacy.
PREVENTIVE CARE
Preventive Screenings and related office visit charge, routine physical exams.
  • Nothing for an annual routine physical and covered preventive screenings.
  • Nothing for an annual routine physical and covered preventive screenings.
DENTAL CARE
Routine Dental Care
  • Benefits paid according to fee schedule in the Service Benefit Plan brochure
  • Your out-of-pocket costs are limited to the MAC
  • $25 copayment per evaluation.
CHIROPRACTIC CARE AND OSTEOPATHIC MANIPULATIVE TREATMENT
Manipulative Treatment
  • Up to 12 spinal manipulations per year.
  • $20 copayment per visit.
  • Up to 20 spinal manipulations per year.
  • $25 copayment per visit.
OTHER BENEFITS
Catastrophic Benefits
  • 100% payment level begins after you pay $5000 out-of-pocket in eligible coinsurance and copayment expenses.
  • 100% payment level begins after you pay $5000 out-of-pocket in eligible coinsurance and copayment expenses.

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Page last updated: December 31, 2012

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