Blue Cross and Blue Shield's Federal Employee Plan - Value of Blue 2010

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 is limited to care performed by Preferred providers, except in certain situations like emergency care. Standard Option also has a calendar year deductible and Basic Option does not. Most care under Basic Option is subject to a copayment amount.

2010 Premiums — Your Share
Standard and Basic Option Comparison Chart
FEP Blue Vision

This is a summary of the features for the year 2010 Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the plan's federal brochure (RI 71-005) [PDF 1.05 MB]. All benefits are subject to the definitions, limitations and exclusions set forth in the 2010 federal brochure.

2010 Premiums — Your Share

	2010 Standard Option	2010 Basic Option
Non-Postal Premium Biweekly	Self Only (104): $80.81 Family (105): $185.06	Self Only (111): $46.50 Family (112): $108.91
Non-Postal Premium Monthly	Self Only (104): $175.08 Family (105): $400.97	Self Only (111): $100.76 Family (112): $235.98
Postal Premium Biweekly	Self Only (104): $57.53 Family (105): $132.83	Self Only (111): $26.97 Family (112): $63.17

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

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

Standard Option And Basic Option Benefit Comparison Chart

Benefit	2010 Standard Option Coverage *	2010 Basic Option Coverage **
PREVENTIVE CARE
Preventive Screenings and related office visit charge, routine physical exams.	$20 office visit copayment for primary care provider $30 office visit copayment for specialists Nothing for covered preventive screenings Members can obtain one co-pay waiver for this service by completing the Blue Health Assessment after Jan. 1, 2010	$25 office visit copayment for primary care provider $35 office visit copayment for specialists Nothing for covered preventive screenings billed by your doctor or independent labs Members can obtain one co-pay waiver for this service by completing the Blue Health Assessment after Jan. 1, 2010
Outpatient consultations, home and office visits, and outpatient second surgical opinions. ***	$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
Inpatient services, including surgery, medical care and outpatient surgery.	Subject to $300 calendar year deductible. 15% PPA	$100 copayment per surgeon Nothing for other covered services
HOSPITAL / FACILITY CARE ***
Hospital Inpatient: Precertification required.	$200 per admission copayment for unlimited days	$150 per day up to $750 for unlimited days
Outpatient Facility Care, except outpatient surgery and physical, occupational and speech therapy	Subject to $300 calendar year deductible. 15% PPA	$75 per day facility copayment
Outpatient Surgery	15% PPA	$75 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.	$75 copayment — emergency room facility $30 copayment — urgent care center $25 copayment — primary care provider $35 copayment — specialists
Medical Emergency Care: Facility care	Subject to $300 calendar year deductible. 15% PPA	$75 copayment — emergency room facility $30 copayment — urgent care center
Medical Emergency Care: Physician care	$20 office visit copayment for primary care provider $30 office visit copayment for specialist 15% PPA for all other services (deductible applies)	$25 copayment — primary care provider $35 copayment — specialists
PRESCRIPTION DRUGS
Mail Service Pharmacy	Up to a 90-day supply. Nothing for the first 4 prescriptions for generic drugs then $10 copayment. $65 each for the first 30 prescriptions for brand name drugs, $50 thereafter	No benefit
Retail Pharmacy ****	Up to a 90-day supply. 20% PPA at time of purchase for generic drugs The coinsurance amount is waived for the first 4 prescription fills or refills when you switch from certain brand name drugs to an eligible generic drug 30% PPA at the time of purchase for brand name drugs	Up to a 34-day supply. 90-day supply for 3 copays $10 copayment for generic drugs $35 copayment for formulary brand name drugs 50% coinsurance or $45 minimum for non-formulary brand or non-preferred brand name drugs
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	$20 copayment per oral exam Benefits limited to 2 exams, X-rays and cleanings per year Sealants for children up to age 16
CHIROPRACTIC CARE
Spinal Manipulations	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.

* When you use Non-preferred facilities and professionals, your out-of-pocket expenses are greater. Please see the 2010 brochure for details.

** Basic Option does not generally provide benefits for services rendered by Non-preferred providers.

*** Prior approval is required for all MHSA outpatient services in order to receive benefits.

**** Members receive 4 free generic re-fills when they switch from a brand listed in the brochure to an eligible corresponding generic. See section 5(f) of the brochure or go to www.caremark.com/fep for details.

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