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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

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2013 Standard and Basic Option Service Benefit Plan Summary


VALUE OF BLUE Choosing the right coverage with the benefits and rates that meet your familys health care needs is important. But there is more to health insurance than just benefits and premiums. There is also the added value that the Service Benefit Plan can bring to you and your familys health and wellness. Like the value of our 24/7 nurse advice line that provides personalized services from people who care about you and your family. Our Preferred provider network of hospitals, physicians, pharmacies and other health care professionals is almost one million strong so you can find a network provider near where you live and nationwide. Plus you save money when you use Preferred providers. You have the security of knowing that the Blue Cross and Blue Shield Service Benefit Plan ID card is not only recognized in the US, but worldwide. We also provide a special free assistance center to help you when you travel overseas. We reward you for managing your health with a $50 MyBlue Wellness Incentive debit card for taking the Blue Health Assessment and up to three online coaching sessions. The value of Blue is all these things and more. And if you need to talk to someone about your questions, you can call our Open Season Information Center at 1.800.411.BLUE beginning October 22 through December 28, 2012. BASIC OPTION Network Providers Under Basic Option, you use Preferred providers for all the medical care you and your family need. Preferred providers file your claims and payment will be made to the provider. Benefits are only available for care performed by Non-preferred providers in certain situations, such as emergency care. EXAMPLE OF YOUR SAVINGS WHEN YOU USE PREFERRED PHYSICIANS

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

DOCTORS OFFICE VISIT PREFERRED PHYSICIAN Physicians charge $250 Our allowance $100 We pay Our allowance minus copayment: $75 Your copayment $25 Plus any difference up to the providers charge$0 TOTAL YOU PAY $25 2013 Basic Option Benefits At-A-Glance Certain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first).Please see the 2013 Service Benefit Plan brochure for more information. (Brochure sections are identified for your reference.) WHAT YOU PAY

SERVICES PREVENTIVE CARE 5(a) and 5(h) Preventive Screenings and related office visit charge, Routine physical exams Well Child Care up to age 22 Preventive Dental Care

2013 BASIC OPTION NETWORK BENEFIT*

Nothing for an annual physical and covered preventive screenings Nothing for covered charges. $25 per evaluation. Benefits limited to 2 evaluation and cleanings per year. Annual X-rays. Sealants for children up to age 16.

PHYSICIAN CARE 5(a) and 5(b) Surgical Care $150 copayment per surgeon. Home and office visits, second surgical opinions and $25 office visit copayment for primary care provider. consultations $35 office visit copayment for specialists. MATERNITY CARE 5(a) Inpatient Hospital Care and Physician Care: Pre-natal and post-natal care and the delivery paid in full. Inpatient hospital charges paid Precertification not required in full, after $150 copayment. Outpatient hospital care paid in full. HOSPITAL/FACILITY CARE 5(c) Hospital Inpatient: Precertification required $150 per day up to $750. Outpatient Facility Care $100 per day per facility copayment. ACCIDENTAL INJURY/MEDICAL EMERGENCY 5(d) Accidental Injury $125 copayment for emergency room. $25 copayment for primary care physician. $35 copayment for specialist. $50 copayment for urgent care center. Medical Emergency/Facility care $125 copayment for emergency room. $50 copayment for urgent care center. Medical Emergency/Professional care $25 copayment for primary care physician. $35 copayment for specialist. CHIROPRACTIC AND OSTEOPATHIC MANIPULATIVE TREATMENT 5(a) Manipulative Treatment Up to 20 manipulations per year. $25 per visit copayment. OTHER BENEFITS 4

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

2013 BASIC OPTION NETWORK BENEFIT* 100% payment level begins after you pay $5000 out-of-pocket in coinsurance and copayment expenses *When you receive care that is performed by a Non-preferred provider, benefits are not available under Basic Option, except in certain situations such as emergency care. STANDARD OPTION More Choices More network providers means more choices. Our nationwide network of almost one million hospitals, physicians, pharmacies and other health care providers makes it easy to use a Preferred provider. And when you use a Preferred provider, the provider files the claim, payment is made to the provider and you are only responsible for any difference between our allowance and our payment. This is also true for Participating providers. You can choose to use Non-participating providers, but your out-of-pocket expenses will be higher than if you used Preferred or Participating providers. EXAMPLE OF YOUR SAVINGS WHEN YOU USE PREFERRED PROVIDERS IN 2013 DOCTORS OFFICE VISIT Physicians charge Our allowance We pay Your coinsurance PREFERRED PHYSICIAN $250 $100 85% of our allowance or $85 15% of our allowance or $15 $0 PARTICIPATING PHYSICIAN NON-PARTICIPATING PHYSICIAN

SERVICES Catastrophic Benefits

WHAT YOU PAY

$250 $100 65% of our allowance or $65 35% of our allowance or $35 $0 $0

$250 $100 65% of our allowance or $65 35% of our allowance or $35 $150 $150

Plus any difference up to the providers charge YOUR TOTAL ESTIMATED PAYMENT $0 2013 Standard Option Benefits At-A-Glance

Certain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first). Please see the 2013 Service Benefit Plan brochure for more information. Brochure sections are identified for your reference. PPA=Preferred Provider Allowance | PA=Plan Allowance | MAC=Maximum Allowable Charge WHAT YOU PAY 2013 STANDARD OPTION PPO BENEFIT

SERVICES

PREVENTIVE CARE 5(a) AND 5(h) Preventive Screenings and related office Nothing for an annual physical and covered 35% PA** visit charge, routine physical exams preventive screenings.

2013 STANDARD OPTION NON-PPO BENEFIT*

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

SERVICES Well Child Care up to age 22 Preventive Dental Care

WHAT YOU PAY 2013 STANDARD OPTION PPO BENEFIT

Nothing for covered charges. Your out-of-pocket expenses are limited to the balance after our payment up to the MAC. PHYSICIAN CARE 5(a) AND 5(b) Surgical Care 15% PPA** 35% PA** Home and office visits, second surgical $20 per visit copayment for primary care 35% PA** opinions and consultations physician. $30 per visit copayment for specialists. MATERNITY CARE 5(a) Inpatient Hospital Care: Precertification Nothing for covered charges. $350 per admission copayment plus 35% PA in not required Non-member hospitals. Physician Care Nothing for covered charges. 35% PA** HOSPITAL/FACILITY CARE 5(c) Hospital Inpatient: Precertification $250 per admission copayment. $350 per admission copayment. required 35% PA in Non-member hospitals. Outpatient Facility Care 15% PPA** 35% PA** ACCIDENTAL INJURY/MEDICAL EMERGENCY 5(d) Accidental Injury within 72 hours of Nothing for covered charges. Nothing for coverage charges. You pay any accident difference between our allowance and billed charge. Medical Emergency/Facility care Emergency Room: 15%PPA** Emergency Room: 15%PA** Urgent Care Center: $40 copayment. Urgent Care Center: $40 copayment. Medical Emergency/Physician care $20 per visit copayment for primary care 15% PA** physician. $30 per visit copayment for specialists. OTHER BENEFITS 4 Catastrophic Benefits 100% payment level begins after you pay $5000 100% payment level begins after you pay $7000 out-of-pocket in coinsurance, copayment and out-of-pocket in coinsurance, copayment and deductible expenses. deductible expenses. *When you use Non-preferred facilities and professionals, your out-of-pocket expenses are greater and you generally pay any difference between our allowance and the billed amount. Please see Section 10 of the 2013 Service Benefit Plan brochure. **Subject to one $350 deductible per member per calendar year, $700 family limit each calendar year. FEP BLUE DIFFERENCE Blue Health Assessment Find out just how healthy your current lifestyle is by taking the Blue Health Assessment, a quick online tool to help you look at your current health status and habits. You get personalized feedback identifying potential health risks, providing suggestions for action and talking points to help you discuss any health issues with your physician. You also earn your MyBlue Wellness Incentive when you complete the Blue

2013 STANDARD OPTION NON-PPO BENEFIT* 35% PA** You are responsible for the balance after our payment, up to the billed charge.

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

Health Assessment. MyBlue Benefit Statements Keeping track of your benefits and out-of-pocket costs can be time consuming. Your MyBlue Benefit Statements summarize your healthcare benefits and expenses in one easy to access location. The Quarterly Statement includes a list of recently processed medical and pharmacy claims and can help you plan and budget for your future healthcare expenses. The Annual Statement provides a summary of the benefits paid for all your claims during the previous year. You can download and print each Statement for your records. MyBlue Personal Health Record MyBlue Personal Health Record provides a secure, central location for you to access, update and store your personal healthcare information, making it easy to manage your healthcare records. It automatically updates your claims information, and you can customize it to meet your needs. You also get a Continuity of Care Record that summarizes all of your medical information so you can create a portable health record to share with your physicians. MyBlue Customer eService MyBlue Customer eService is like having your own personal customer service representative when you need help managing your enrollment. You can view your Explanation of Benefits online, request duplicate ID cards, change your address, add children after a birth or adoption and let us know about a marriage or divorce. Our Audio Health Library The AudioHealth Library is available to help you and your family educate yourselves about many chronic and common illnesses and diseases. It is available 24 hours a day, every day. These pre-recorded messages are available two ways. First you can call Blue Health Connection at 1.888.258.3432 to listen to a topic. Or you can access the Blue Health Connection online. You can browse the topics and read them online or download them to your mp3 player to listen to anytime. Online Explanation of Benefits You can decide to go paperless and access your explanation of benefits online through MyBlue Customer eService. You can see and print information for claims processed for you and your family. It is easy to opt-in to paperless EOBs. First, sign on to www.fepblue.org/myblue. On the MyBlue Welcome page, select Go Green: Opt out of paper EOBs under My Benefits. This link takes you to MyBlue Customer eService. Once you opt out of paper EOBs, you will get an email when a new EOB has been posted for you to view. The online EOB looks just like the paper version and if you wish, you can print a copy. Blue Health Connection Blue Health Connection is your resource for answers to your medical questions. If you need medical information in the middle of the night or

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

just some answers to your health-related questions day or night, our Blue Health Connection nurses are there to help. You can call 1.888.258.3432 for immediate assistance or have a chat online any time. WELLNESS & DISCOUNT PROGRAMS Online Coaching Sessions If you need help reaching your health and wellness goals or maybe just a push in the right direction, these online coaching sessions are for you. Each of the twelve coaching sessions provides feedback, advice and information about positive lifestyle changes. These modules cover a variety of topics from stress management to nutrition. Plus, you receive $5 credit on your health debit card if you complete up to three online coaching sessions. Weight Management Center Our new online Weight Management Center puts everything you need in one location. It gets you started by taking the Blue Health Assessment to create a personalized action plan. The Center also has direct links to weight management, healthy eating and exercise online coaching sessions that provide feedback and advice on how to meet your goals. Other healthy eating and exercise resources are also available, including a link to our health club membership page, WalkingWorks online information and weekly nutritional articles. Smoking Cessation If you are ready to stop smoking, we have the support you need for success starting with our online coaching session for smoking cessation, Breathe. This module provides an interactive program just for you, to help set goals, track results and ultimately improve your health by not smoking. You also get personalized emails in the Secure Message Center on Blue Health Connection for support and encouragement. After your complete Breathe, we have additional incentives for you to stop smoking. When you use a Preferred pharmacy to obtain certain prescription smoking cessation medications, we will waive the cost share under both options. In addition, we will provide benefits in full for specific over-the-counter smoking cessation medications when you purchase the medications at a Preferred pharmacy and have a doctors prescription. Health Club Memberships You pay a $25 initiation fee and $25 monthly for unlimited visits to any of our over 8,000 fitness facilities nationwide. You are not limited to a specific facility. Other Wellness Programs WalkingWorks is a good start for any exercise routine. Blue365 offers access to information, discounts and savings that make it easier and more affordable to make healthy choices. Our Vision Care Affinity Program provides savings on routine eye exams, frames, lenses, contact lens and laser vision correction when you use a network provider. Visit FEP BlueVision for additional information about this program or call 1.800.551.3337.

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

Local Care Management Programs, offered by local Blue Cross and Blue Shield Plans, provide patient education and support for select diagnoses. Call your local Blue Cross and Blue Shield Plan for more information about these programs. MYBLUE INCENTIVES MyBlue Wellness Card The MyBlue Wellness Card is a pre-paid card we use to reward our members for taking charge of their health. The MyBlue Wellness card is available to members who complete the Blue Health Assessment and up to three online coaching sessions. You can also earn rewards as part of our Diabetes Management Incentive Program. Blue Health Assessment Earn $35 When you complete your Blue Health Assessment for 2013, you are entitled to receive a $35 health debit card to use for qualified medical expenses. Family contracts are eligible to receive two $35 cards when two adult members complete the Blue Health Assessment. Please note: For members who received a MyBlue Wellness Card in 2011 or 2012, your new credit of $35 will be applied to your existing health debit card. Online Coaching Sessions Earn $15 You can earn an additional $15 by completing up to three online coaching sessions. For each session you complete, you receive a $5 credit on your health debit card. Please note: The $5 credit for online coaching sessions does not apply to completion of the BreatheTM module for smoking cessation. Diabetes Management Incentive ProgramEarn $75 The Diabetes Management Incentive Program provides critical education if you have diabetes, assists in improving your blood sugar control and helps to manage or slow the progression of complications related to diabetes. To be eligible for this program, you must be 18 years of age or older and complete either the Blue Health Assessment and indicate you have diabetes or the initial questionnaire for the Care for Diabetes online coaching sessions. This program is limited to two adult members if you have family coverage. You will receive health debit card credits when you complete specific activities. Please note: Once you earn the maximum of $75 under the Diabetes Management Incentive Program, you will not earn additional credits to your health debit card for completing additional activities under this incentive. ACTIVITY Completion of Blue Health Assessment. Completion of three online coaching sessions, $5 per session. TOTAL MAXIMUM CREDIT TOTAL MAXIMUM CREDIT DIABETES MANAGEMENT INCENTIVE PROGRAM A1c tests performed by a covered provider, maximum of two per year, $10 each. Reporting A1c levels, maximum of two per year, $5 each. CARD CREDIT $35 $15 $50 $50 $20 $10

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

ACTIVITY CARD CREDIT Purchasing diabetic glucose strips through our Retail or Mail Service Pharmacy, maximum of 4 per year, $10 each.$40 Diabetic foot exam from a covered provider, maximum of one per year, $10. $10 $20 One of the following activities: $20 for enrolling in a diabetic disease management program, one per year. $20 for a diabetic visit to a covered provider, one per year. $5 each for completing web based diabetes education programs on our web site, up to four per year. TOTAL MAXIMUM CREDIT $75 PHARMACY PROGRAMS Mail Service Pharmacy Standard Option Only The Mail Service Pharmacy Program for Standard Option is an easy way to obtain medications you take every day for a chronic condition with the convenience of home delivery. If you have any questions about the Mail Service Pharmacy or want to talk to a pharmacist about your medications, you can call 1.800.262.7890 anytime. This benefit is not available under Basic Option. Using the Mail Service Pharmacy is easy. 1. Ask your physician to prescribe up to a 90-day supply (minimum 21-day supply) of your medication plus refills for up to one year. 2. Send your original prescription, the appropriate copayment amount and your completed mail service order form to the address on the form. You can request order forms online or by calling 1.800.262.7890. 3. Or you can ask you doctor to order a prescription for you by calling 1.800.262.7890 and pressing Option 1. 4. All medications and instructions are sent via US Postal Service, except for medications that require overnight shipping. You should receive your prescription within 14 days from the time you mail in your order. 5. You can order refills by sending in the refill slip included with your previous prescription fill, you can order refills online under Pharmacy Programs, or you can call 1.877.337.3455 24/7 to order your refills.

Retail Pharmacy Program Both Options Basic Option members must use a Preferred retail pharmacy or our Internet pharmacies to obtain medications. Standard Option members can use any Preferred or Non-preferred local retail pharmacy or Internet pharmacy. However, if you use a Non-preferred pharmacy, you pay the full cost of the drug and then file a claim for reimbursement. Your cost share is 45 percent of the Average Wholesale Price, plus any difference between our allowance and the billed amount. Just show your Service Benefit Plan ID card at a Preferred pharmacy. You pay only the appropriate copayment or coinsurance amount. If you have any questions about the Retail Pharmacy Program, you can call 1.800.624.5060 to talk to a member service representative. We have over 60,000 Preferred Network retail pharmacies nationwide along with our Internet Pharmacies. You can locate a Preferred retail

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

pharmacy near you by calling 1.800.624.5060 or by using the Provider Directory. BENEFIT Mail Service Pharmacy 2013 STANDARD OPTION COVERAGE 2013 BASIC OPTION COVERAGE Not a benefit.

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. Retail Pharmacy Up to a 90-day supply. Nothing for the first four prescription fills or refills when you Program switch from certain brand-name drugs to specific generic drugs when you use a Preferred Pharmacy. Tier 1 (generics): 20% PPA. Tier 2 (Preferred brand-name): 30% PPA. Tier 3 (Non-preferred brand-name): 45% PPA. WORLDWIDE COVERAGE When You Live or Travel Overseas

Up to a 34-day supply. 90-day supply for 3 copayments. Tier 1 (generics): $10 copayment. Tier 2 (Preferred brand-name): $40 copayment. Tier 3 (Non-preferred brand-name): 50% coinsurance or $50 minimum.

If you need medical care outside the United States, you can be assured that your Blue Cross and Blue Shield Service Benefit Plan ID card entitles you to world class service. Your Service Benefit Plan coverage protects you around the world. Overseas Assistance Center Our Overseas Assistance Center offers help when you are traveling outside the US, Puerto Rico and the US Virgin Islands. 24 hours a day, seven days a week. Bilingual operators are also available to help you. The Center can help you locate a provider and you can call the Center collect at 804.673.1678 or email the center at fepoverseas@axaassistance.us for assistance. How Benefits Work Overseas Inpatient Hospital Care: Under both options, benefits are paid at the Preferred level. Precertification is not required for hospital admissions outside the US. Outpatient Hospital Care: Benefits under Standard and Basic Option are paid at the Preferred level. Physician Care: Physician care and care by other covered professional providers performed outside the US are paid at the Preferred level using a customary percentage of the billed charge or a provider negotiated amount. Prescription Drugs: Drugs and medications that require a prescription overseas may differ from those that require a prescription in the US.

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

Drugs purchased outside the US must be an equivalent product that by US Federal law require a prescription for purchase in the US or there must be clinical evidence that prescribing the drug is consistent with the standard of medical practice in that country. Standard Option members can order prescription drugs through the Mail Service Pharmacy if your address has a US zip code and the prescribing physician is licensed in the US. For both Standard and Basic Option, if you purchase a prescription drug at a local pharmacy outside the US, you pay for the medication and then file a claim for reimbursement. Payment will be made at the Preferred level. Filing Claims Members can mail claims to us, fax them to us or submit claims for medical care performed and prescription drugs purchased overseas through MyBlue Portal. For information about mailing and faxing claims to us see Section 5(i) in the Service Benefit Plan brochure. To submit your claims electronically: 1. Go to MyBlue Portal and log-in if you have already registered. If not, you will have to set up a MyBlue account. 2. On the MyBlue Welcome page, select Submit Overseas Claims Online. 3. Follow the step-by-step directions to submit the claim, including completing the fillable claim form PDF, scanning your bills, and uploading the files. You can also take advantage of bank wire payment and get your payment faster for overseas medical claims. You can select to have the wire payment in a foreign currency or US dollars. Just complete Section 6 of the online overseas medical claim form to select wire payments and the currency you prefer. Payments for covered drugs and supplies you purchase from pharmacies outside the U.S., Puerto Rico, and the U.S. Virgin Islands can only be made by check in US dollars. 2013 Standard Option and Basic Option Benefit Comparison Chart Certain deductibles, copayments and coinsurance amounts do not apply if Medicare is your primary coverage for medical services (it pays first). PPA = Preferred Provider Allowance | MAC = Maximum Allowable Charge WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS 2013 STANDARD OPTION COVERAGE* Subject to $350 calendar year deductible. 15% PPA. $20 per visit copayment for primary care provider. $30 per visit copayment for specialist.

BENEFIT PHYSICIAN CARE Surgical Services Office visits and outpatient consultations

2013 BASIC OPTION COVERAGE* $150 copayment per surgeon $25 per visit copayment for primary care provider. $35 per visit copayment for specialists.

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

BENEFIT

WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS 2013 STANDARD OPTION COVERAGE*

Routine exams and other preventive care Nothing for covered services. services HOSPITAL/FACILITY CARE Hospital Inpatient: Precertification required $250 per admission copayment for unlimited days. Outpatient Facility Care, except physical, occupational and speech therapy PRESCRIPTION DRUGS*** Mail Service Pharmacy (For information about Tier 4 specialty drug benefits, see Section 5(f) of the 2013 Service Benefit Plan brochure.) Subject to $350 calendar year deductible. 15% PPA.

2013 BASIC OPTION COVERAGE* Nothing for covered services. $150 per day up to $750 for unlimited days. $100 per day facility copayment.

Up to a 90-day supply. Nothing for the first four prescription fills Not a benefit. 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. Retail Pharmacy Program Up to a 90-day supply. Nothing for the first four prescription fills Up to a 34-day supply. 90-day (For information about Tier 4 specialty drug or refills when you switch from certain brand-name drugs to supply for 3 copayments. benefits, see Section 5(f) of the 2013 specific generic drugs when you use a Preferred Pharmacy. Tier 1 (generics): $10 Service Benefit Plan brochure.) Tier 1 (generics): 20% PPA. copayment. Tier 2 (Preferred brand-name): 30% PPA. Tier 2 (Preferred brand-name): Tier 3 (Non-preferred brand-name): 45% PPA. $40 copayment. Tier 3 (Non-preferred brandname): 50% coinsurance or $50 minimum. *When you use Non-preferred facilities and professionals, your out-of-pocket expenses are greater. Please see the 2013 brochure for details. **Basic Option does not generally provide benefits for services rendered by Non-preferred providers. ***Benefits for generic prescription drugs are different if you have Medicare Part B as your primary coverage. Please see the 2013 brochure for details.

WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS BENEFIT 2013 STANDARD OPTION COVERAGE* 2013 BASIC OPTION COVERAGE* ACCIDENTAL INJURY/EMERGENCY CARE Accidental Injury Care: Nothing for covered charges for services performed within $125 copayment emergency room. Physician and facility care 72 hours of accident. $25 copayment primary care provider. $35 copayment specialists. $50 copayment urgent care center. Medical Emergency Care: Emergency Room: Subject to $350 calendar year Emergency Room: $125 copayment. Facility care deductible. 15% PPA. Urgent Care Center: $50 copayment. Urgent Care Center: $40 per visit copayment

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Blue Cross and Blue Shield's Federal Employee Plan - Benefit Plans - 2013 Benefits Summary

http://fepblue.org/benefitplans/sbp-brochure/2013-summary.jsp

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 2013 brochure for details. **Basic Option does not generally provide benefits for services rendered by Non-preferred providers. As You Make Your Open Season Choices The 2013 Blue Cross and Blue Shield Service Benefit Plan brochure is your best resource for detailed information about the benefits and services most important to you. Please do not rely solely on the summary of benefits. You can access and download a copy of our 2013 brochure online. This is a summary of the features for the year 2013 Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the plans federal brochure (RI 71-005). All benefits are subject to the definitions, limitations and exclusions set forth in the 2013 federal brochure. Page last updated: January 31, 2013 2000-2013 Blue Cross and Blue Shield AssociationAll Rights Reserved

Benefits paid according to fee schedule in the Service Benefit Plan brochure. Your out-of-pocket costs are limited to the MAC. CHIROPRACTIC AND OSTEOPATHIC MANIPULATIVE TREATMENT Manipulative Treatment Up to 12 manipulations per year. $20 per visit copayment. OTHER BENEFITS Catastrophic Benefits 100% payment level begins after you pay $5000 out-ofpocket in eligible coinsurance and copayment expenses.

BENEFIT Medical Emergency Care: Physician care DENTAL CARE Routine Dental Care

WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS 2013 STANDARD OPTION COVERAGE* 2013 BASIC OPTION COVERAGE* $20 per visit copayment for primary care provider. $25 per visit for primary care provider. $30 per visit copayment for specialist $35 per visit copayment for specialists $25 copayment per evaluation.

Up to 20 manipulations per year. $25 per visit copayment.

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