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2014 Benefit Changes
BlueCross and BlueShield
Service Benefit Plan
Blue Cross Blue Shield Association is an Association of independent Blue Cross and Blue Shield companies.
2
Plan Overview
• Preventive Care
• Health Club Membership
Agenda
• Special Features
2014 Benefits Changes
2014 Rates
Service Benefit Plan Options
• The Service Benefit Plan is a fee-for-service (FFS) plan
• We have a Preferred Provider Organization (PPO)
Basic Option
Standard Option
• Deductible
• Copayments and
Coinsurance
• Ability to Choose
Provider (Preferred and
Non-preferred)
• Retail and Mail Rx
• No deductibles
• Copayment based
• Preferred Providers
only
• Retail Rx
Standard Option & Basic Option
• No Pre-Existing Conditions
• No Referrals Required
• No Lifetime Maximums
• Unlimited I/P Hospital Days
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Preventive Care
• Free Preventive Care (Preferred Providers)
• Free annual physicals for adults
• Free well child care from birth up to the age of 22
• Free cancer screenings
• Free immunizations
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Health Club Membership
Healthways Fitness Your Way
• Online enrollment payment
• $25 one time initiation fee
• $25/month (3 months minimum)
• Unlimited access to >8000 fitness centers
• Web tools, trackers and online health tracking
• Ongoing engagement through social networking and gaming
–
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2014 Benefits Changes
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2014 Benefit Changes
• BRCA Testing
• Vitamin D Supplements
• Catastrophic Maximums
• Prescription Drugs
• Basic Option Copayments
• Wellness Incentives
• Other Changes
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Preventive BRCA Testing
Standard Option and Basic Option
• Current Benefit:
– Benefits are not available for BRCA testing when no condition is present
• 2014 Benefit:
– Benefits are available for BRCA testing, limited to one per lifetime, for:
• Female members without personal diagnosis of breast or ovarian
cancer who meet specific family history criteria; no member-cost share
when provider is Preferred
• Male or Female members with a cancer diagnosis when test is
medically necessary to manage treatment of cancer; regular medical
benefits apply
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Vitamin D Supplements
Standard Option and Basic Option
• Current Benefit:
– Benefits are not available for Vitamin D supplements
• 2014 Benefit:
– Benefits are available with no member cost-share for Vitamin D supplements for
adults, age 65 and over:
• When prescribed by a physician;
• When obtained from a Preferred retail pharmacy; and
• Limited to 600-800 international units (I.U.s) daily
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Catastrophic Out-of-Pocket
Maximums
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Catastrophic Maximum – Standard Option
• Current Benefit:
– The calendar year deductible does not count toward the catastrophic
protection out-of-pocket maximum
• 2014 Benefit:
– Include the calendar year deductible in calculation of the catastrophic
maximum
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Standard Option: Catastrophic
Out-of-Pocket Maximums
Current
Preferred
Non-Preferred
Self Only
$5,000
$7,000
Self and Family
$5,000
$7,000
Preferred
Non-Preferred
Self Only
$5,000
$7,000
Self and Family
$6,000
$8,000
2014
*Basic Option limited to Preferred providers
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Catastrophic Maximum – Basic Option
• Current Benefit:
– The member cost-share for Tier 3 (non-preferred brand-name) drugs does not
apply toward the catastrophic maximum
• 2014 Benefit:
– Apply the member cost-share for Tier 3 (non-preferred brand-name) drugs toward
the catastrophic maximum
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Basic Option: Catastrophic
Out-of-Pocket Maximums
Current
Preferred
Non-Preferred
Self Only
$5,000
N/A
Self and Family
$5,000
N/A
Preferred
Non-Preferred
Self Only
$5,500
N/A
Self and Family
$7,000
N/A
2014
*Basic Option limited to Preferred providers
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Basic Option Surgical Copayment
• Current Benefit:
– Member copayment = $150 per surgeon, regardless of place of service
(Special exceptions exist for some minor procedures to be treated as
office visit with copayment).
• 2014 Benefit:
– Member copayment = $150 per surgeon for surgical procedures
performed in an office setting
– All other settings, a $200 copayment per surgeon will apply
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Basic Option Inpatient Admission
Copayment
• Current Benefit:
– Member copayment = $150 per day for inpatient admission
(maximum of $750 per admission)
• 2014 Benefit:
– Member copayment = $175 per day for inpatient admission
(maximum of $875 per admission)
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Basic Option Diagnostic Test
Copayments
• Current Benefit:
– No cost-share for neurological testing
– $25 copayment for low-cost diagnostic tests
– $75 copayment for professionally-billed high-cost diagnostic tests
– $100 copayment for facility-billed high-cost diagnostic tests
• 2014 Benefit:
– $40 copayment for neurological tests and other low-cost diagnostic tests
– $100 copayment for professionally-billed high-cost diagnostic tests
– $150 copayment for facility-billed high-cost diagnostic tests
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Wellness Incentives
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Health Assessment Incentive
• Current Benefit:
– Members receive up to $50 on a wellness incentive card for completing
the Blue Health Assessment ($35) and up to 3 online coaching modules
($5 each) during the calendar year
• 2014 Benefit:
– Members receive up to $75 on a wellness incentive card for completing
the Health Assessment ($40) and achieving up to 3 of 5 lifestyle goals
($15 for first goal; $10 each for two additional goals) during the calendar
year. Lifestyle goals include exercise, nutrition, stress, weight
management, and emotional health
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Other Changes
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Insulin and Diabetic Supplies
• Current Benefit:
– Members can obtain insulin and diabetic supplies from professional
providers or through the pharmacy program(s)
• 2014 Benefit:
– Limit benefits for insulin and diabetic supplies to be dispensed
exclusively through the pharmacy program(s)
– Except for members with primary coverage under Medicare Part B,
exclude coverage for insulin and diabetic supplies dispensed by
professional providers
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Wigs
• Current Benefit:
– Benefits are available for one wig per lifetime, up to a $350 maximum, for
hair loss due to chemotherapy for the treatment of cancer
• 2014 Benefit:
– Benefits are available for one wig per lifetime, up to a $350 maximum, for
hair loss due to the treatment of cancer
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Home Nursing Care Visits
(Standard Option only)
• Current Benefit:
– 25 home nursing care visits, limited to 2 hours per visit, per calendar
year
• 2014 Benefit:
– 50 home nursing care visits, limited to 2 hours per visit, per calendar
year
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Acupuncture Limitations
(Basic Option only)
• Current Benefit:
– For Basic Option, current acupuncture benefit includes an unlimited
number of visits, but limited to physicians only
• 2014 Benefit:
– Limits Basic Option acupuncture visits to 10 per calendar year (with all
licensed providers now allowed to bill)
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2014 Rates
Standard Option
Basic Option
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Enrollment Codes
Standard Option
– 104 Self Only
– 105 Self and Family
Basic Option
– 111 Self Only
– 112 Self and Family
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2014 Rates – Standard Option (Non-Postal Rates)
Bi Weekly
Monthly
• Self 104
87.82 (+1.91)
190.28 (+4.14)
• Family 105
204.98 (+4.84)
444.12 (+10.49)
Source
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2014 Rates – Basic Option (Non-Postal Rates)
Bi Weekly
Monthly
Self 111
60.96 (+1.89)
132.08 (+4.10)
Family 112
142.75 (+4.43)
309.29 (+9.60)
Pharmacy Programs
Blue Cross and Blue Shield Service Benefit Plan
2013 HBO Open Season Seminar
Blue Cross Blue Shield Association is an Association of independent Blue Cross and Blue Shield companies.
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• Pharmacy Programs Overview
Agenda
• 2014 Tier Structure
• 2014 Benefits
• Member Resources
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Pharmacy Program Overview for 2014
• Continuation of…
– CVS/Caremark Administration
– Generic Incentive Program
– Medicare Part B member savings
• Added Tier 5 in Specialty Program
• Enhanced Diabetic Benefit
• Affordable Care Act Impact
– Basic Option non-Preferred Brand cost share now applies to Catastrophic Benefit
– Vitamin D supplements with a prescription for members over 65
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2014 Tier Structure
• Tier 1 – Generics (least out-of-pocket)
• Tier 2 – Preferred Brands (moderate out-of-pocket)
• Tier 3 – non-Preferred Brands (most out-of-pocket)
• Tier 4 – Specialty Preferred
• *Tier 5 – Specialty non-Preferred
– *New for 2014
– Letter mailing to impacted members
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2014 Standard Option Benefits
Preferred Retail
Pharmacy
Non-Preferred
Retail Pharmacy
Mail Order
Pharmacy
(Up to 90 day supply)
Specialty Pharmacy
(Limit of up to 30 day supply for first 3
fills)
Tier 1
Tier 2
Tier 3
Tier 4
Tier 5
Generic Medication
Preferred Brand Name
Medication
Non-Preferred Brand
Name Medication
Preferred Specialty
Medication
Non-Preferred
Specialty Medication
30% of the plan
allowance
45% of the plan
allowance
30% of the plan
allowance
1st fill ONLY at retail
30% of the plan
allowance
1st fill ONLY at retail
45%
45%
45%
45%
Up to $80
Up to $105
Up to 30-day supply
Up to $35
Up to 30-day supply
Up to $55
Up to 90-day supply
(after 3 fills)
Up to $95
Up to 90-day supply
(after 3 fills)
Up to $155
20% of the
plan allowance
Medicare B Members:
15% of the plan allowance
45%
Up to $15
Medicare B Members:
Up to $10
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2014 Basic Option Benefits
Tier 1
Preferred Retail
Pharmacy
(Up to 30-day
supply)
Specialty
Pharmacy
(Limit of up to 30 day supply for first
3 fills)
Tier 2
Tier 3
Generic
Medication
Preferred Brand
Name Medication
Non-Preferred
Brand Name
Medication
Up to $10
Up to $45 for
30 day supply
50%
($55 minimum)
Tier 4
Tier 5
Preferred Specialty
Medication
Non-Preferred
Specialty
Medication
Up to $60 for up to a
30-day supply only
Up to $80 for up to a
30-day supply only
1st fill ONLY at retail
1st fill ONLY at retail
Up to 30-day supply
Up to $50
Up to 30-day supply
Up to $70
Up to 90-day supply
(after 3 fills)
Up to $140
Up to 90-day supply
(after 3 fills)
Up to $195
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Enhanced Diabetic Benefit
• Insulin and supplies available through pharmacy benefit
– Medical Benefit available to Medicare Part B members
– Free Diabetic Meter Program
– $0 cost share for selected meters ACCU-CHEK or OneTouch
• Preferred strips – Tier 2
– Alcohol Swabs covered with a prescription
– Toll free number 855.582.2024
• Delivered 7-10 business days after the request
– Letters will be sent to diabetic members
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Generic Incentive Program
• Program will continue in 2014
– Started in 2010
– Increase generic alternative awareness
– Generics contain same active ingredient as brands
– Save member out-of-pocket costs
– Change from brand to generic in specific categories
– Copay and Coinsurance waiver
– List of drugs on brochure page _ _ _
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Member Resources
• Retail Pharmacy Program
– (800) 624-5060
– Available 24/7
• Mail Pharmacy Program
– (800) 262-7890
– Available 24/7
• Specialty Pharmacy Program
– (888) 346-3731
– M-F 7am- 9pm
– S/S 8am-6:30pm
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Questions
Contact Information
FEP BlueDental
Easy to do Business With!
HBO Seminar -- 2013
Blue Cross Blue Shield Association is an Association of independent Blue Cross and Blue Shield companies.
40
Agenda
Why Dental?
2014 Premiums
Benefit Summary
FEP Dental Network
FEP BlueDental Value
Contact Information
Questions
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2014 Premiums (monthly rate)
Rating Area
High
Option
Self Only
High Option
Self Plus One
High Option
Self and
Family
Standard
Option Self
Only
Standard
Option Self
Plus One
Standard Option Self
and Family
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
1
$35.40
$70.85
$106.25
$20.35
$40.76
$61.10
2
$40.30
$80.62
$120.92
$23.16
$46.35
$69.51
3
$44.66
$89.35
$134.01
$25.65
$51.35
$77.00
4
$47.17
$94.40
$141.57
$27.06
$54.17
$81.23
5
$52.17
$104.39
$156.56
$29.92
$59.91
$89.83
International
$52.17
$104.39
$156.56
$29.92
$59.91
$89.83
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It’s More Than You Expect
• All FEP BlueDental members receive 2 paid-in-full exams and cleanings
when they see an in-network provider
• With FEP BlueDental, members have in-network preventive and diagnostic
treatments available at no cost
• There are no calendar year deductibles applied to services performed by an
in-network provider
• Orthodontic benefits available (covering 50% of allowed amount) for both
children and adults following a 12 month waiting period
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A Benefit for All Your Dental Needs
FEP BlueDental has four types of covered services:
•Class A (Basic) – Preventive and Diagnostic
IN-NETWORK
OUT-OF-NETWORK
we pay:
we pay:
HIGH OPTION
100%
90%
STANDARD
OPTION
100%
60%
•Class B (Intermediate) – Fillings, minor endodontic, minor
periodontal
IN-NETWORK
OUT-OF-NETWORK
we pay:
we pay:
HIGH OPTION
70%
60%
STANDARD OPTION
55%
40%
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A Benefit for All Your Dental Needs
FEP BlueDental has four types of covered services:
•Class C (Major) – major restorative, endodontic, periodontal and
prosthodontic services
IN-NETWORK
OUT-OF-NETWORK
we pay:
we pay:
HIGH OPTION
50%
40%
STANDARD OPTION
35%
20%
•Class D -- Orthodontic Services - 50% for High & Standard for
both in and out of the network
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A Benefit for All Your Dental Needs
• High Option annual benefit maximum for non-orthodontic services is $10,000
for in-network services and $3,000 for out-of-network services
• Standard Option annual benefit maximum for non-orthodontic services is
$1,500 for in-network services and $750 for out-of-network services
• Lifetime maximum for High Option orthodontic services is $3,500 for both innetwork and out-of-network services
• Lifetime maximum for Standard Option orthodontic services rendered by an
in-network provider is $2,000 and services rendered by an out-of-network
provider are subject to a $1,000 limitation.
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Provider Network
• Providers in all 50 states and includes more than 85,000 unique dentists and
199,000 access points
• If you have Service Benefit Plan (SBP) your in-network provider will file
directly with the local BCBS Plan for primary coverage and then the claim will
be sent to FEP BlueDental
• Dental network may be different from medical network
• Specialties included in the network are: Endodontics, General Dentistry, Oral
Maxilofacial Surgery, Orthodontics, Pediatric Dentistry, and Periodontics
• Provider nominations are welcome
• To find a provider visit our web site (www.fepblue.org) or call us at
855.504.BLUE (2583)
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International Benefits
• The International Dental Program includes English-speaking dentists in
approximately 100 countries worldwide
• You will only receive in-network benefits levels if you use a dentist in our
International Dental Program
• You are responsible for paying the dentist (we will reimburse you in US $’s)
and for submitting claims to the following address:
FEP BlueDental Claims
PO Box 75
Minneapolis, MN 55440-0075
• Claims are available on our website at www.fepblue.org. You may use this
website to get other benefit related information or call us at:
855-504-BLUE(2583), TTY number 1-888-853-7570
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Contact us today to get the
FEP BlueDental coverage you deserve
1.855.504.BLUE (2583)
TTY 1-888-853-7570
Call Center Hours (EST):
• Monday through Friday: 8:00 a.m. – 8:00 p.m.
Or visit www.fepblue.org any time!
To enroll: Visit www.benefeds.com or call 1.877.888.FEDS
FEP BlueVision:
Take a new look at eyecare
Health Benefits Officer Seminar
Fall 2013
Blue Cross Blue Shield Association is an Association of independent Blue Cross and Blue Shield companies.
50
FEP BlueVision - It’s More Than You Expect
• You receive an annual eye exam with no copay when you see a
participating provider
• Eyeglass wearers have many lens options available at no cost or at
discounted copays
• You can receive a generous frame allowance toward ANY frame you
choose or you may select a frame from our Exclusive Collection that is
covered-in-full with no copay
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2014 Premiums
Biweekly & Monthly
Premiums
High
Standard
Biweekly
Monthly
Biweekly
Monthly
Self Only
$4.67
$10.12
$3.69
$8.00
Self + One
$9.36
$20.28
$7.39
$16.01
Self + Family
$14.04
$30.42
$11.08
$24.01
We continue to enhance benefits making it affordable to care for your vision. Without
increasing premiums!
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A Benefit For Your Vision
Plan Feature/
In-Network Benefits
Lenses
High Option
Standard Option
Basic Lens Covered in Full Annually
Basic Lens Covered in Full Annually
$150 allowance plus 20% off overage/1 Annually
$130 allowance plus 20% off overage/1 Every
Other Year
Covered in Full Annually
Covered in Full Every Other Year
Frame
Allowance
OR
FEP BlueVision
Exclusive Collection
Contact Lens
Contact Lens
(in lieu of eyeglasses)
1/ Additional
$150 allowance plus 15% off overage
Annually
Evaluation, fitting and follow-up fees fully
covered for non-specialty lenses and
covered up to $60 for specialty contact
lenses.
discounts not applicable at Costco, Sam’s Club or Walmart locations
* For a complete description, please refer to your benefit brochure.
$130 allowance plus 15% off overage
Annually
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More Benefits!
Optional Lenses and
Treatments
High Option
Standard Option
Average Retail
Ultraviolet Coating
$0
$0
$28
Plastic Photosensitive
Lenses (Transitions)
$0
$65
$123
Scratch Resistant
Coating
$0
$0
$25-$45
Standard
Progressives
$0
$50
$173
Premium
Progressives
$90
$90
$248
Standard AntiReflective Coating
$35
$35
$60
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We provide a convenient network for you
The FEP BlueVision network is specific to routine vision care and
is different from the member’s medical plan network.
•
More than 41,000 points of access
•
Includes: ophthalmologists, optometrists, and many top national retail
providers
•
12% ophthalmologists
•
88% optometrists
•
74% independents
•
26% retail
•
Costco, with 439 locations nationwide, joining network in 2014
•
Exceeds OPM’s access standards
•
Provider nominations are welcome
•
Visit our Web site (www.fepblue.org) or call us at 888-550-2583
55
Contact us today to get the FEP Bluevision
coverage you deserve
1.888.550.BLUE (2583)
TTY 1.800.523.2847
Call Center Hours (EST):
• Monday through Friday: 8:00 a.m. – 11:00 p.m.
• Saturday: 9:00 a.m. – 4:00 p.m.
• Sunday: 12:00 p.m. – 4:00 p.m.
Or visit www.fepblue.org any time!
To enroll: Visit www.benefeds.com or call 1.877.888.FEDS