2014

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Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary

12014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary

While it’s important to choose the right healthcare

coverage with benefits and rates that meet your needs

and those of your family, there is more to health

insurance than benefits and premiums. The Blue Cross

and Blue Shield Service Benefit Plan (Service Benefit

Plan) offers added value in the form of programs and

services that were designed with you and your family’s

health and wellness in mind.

This includes the value of our 24/7 Nurse Line that

provides reliable, personalized advice from

knowledgeable registered nurses.

Our Preferred provider network of hospitals, physicians,

pharmacies and other healthcare professionals is almost

one million strong, so you can find a network provider

near where you live or travel nationwide. Plus, you save

money when you use Preferred providers.

You have peace of mind knowing that the Blue Cross and

Blue Shield Service Benefit Plan ID card is recognized in

the U.S. and around the world.

We also provide a special free assistance center to help

you when you travel overseas.

We reward you for taking charge of your health with

our Wellness Incentive Program. You can earn up to $75

on a health card for taking the Blue Health Assessment

and achieving goals related to a healthy lifestyle.

The value of Blue is all these things and more. Learn

more about what the Service Benefit Plan offers by

reading the information in this book.

You can also learn more about our 2014 benefits

and value-added programs on our website:

www.fepblue.org.

If you would like to talk to someone about your

questions, you can call our Open Season Information

Center at 1-800-411-BLUE beginning October 21

through December 20, 2013.

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32014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary2

WHAT YOU PAYSERVICES 2014 BASIC OPTION NETWORK BENEFIT*

PREVENTIVE CARE — 5(a) and 5(h)

Preventive screenings and related office visit charge; routine physical exams

Nothing for an annual physical and covered preventive screenings

Preventive care for children, up to age 22 Nothing for covered services

Routine dental care $25 copayment per evaluation up to 2 per calendar yearPreventive care only

PHYSICIAN CARE — 5(a) and 5(b)

Surgical care $150 copayment per performing surgeon in an office setting $200 copayment per performing surgeon in another setting

Office visits, consultations and second surgical opinions $25 per visit copayment for primary care provider$35 per visit copayment for specialists

MATERNITY CARE — 5(a)

Inpatient/Outpatient hospital care (Precertification is not required for normal delivery)

$175 copayment per inpatient admission; No out-of-pocket expenses for outpatient covered services

Physician care Physician care including delivery and pre and postnatal care: No out-of-pocket expenses for covered services

HOSPITAL/FACILITY CARE — 5(c)

Inpatient hospital/facility care Precertification is required

$175 per day up to $875 per admission for unlimited days

Outpatient hospital/facility care $100 per day per facility copayment

ACCIDENTAL INJURY/MEDICAL EMERGENCY — 5(d)

Accidental injury and medical emergency $125 copayment for emergency room care$50 copayment for urgent care centerRegular benefits for physician care

CHIROPRACTIC AND OSTEOPATHIC MANIPULATIVE TREATMENT — 5(a)

Manipulative treatment $25 per visit copayment up to 20 manipulations per year

OTHER BENEFITS — 4

Catastrophic benefits 100% payment level begins after you pay $5,500 (Self Only) or $7,000 (Self and Family) out-of-pocket in eligible coinsurance and copayment expenses

Under Basic Option, you must 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.

* 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.

2014 Basic Option Benefits At-A-GlanceCertain cost-sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first). Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for more information. (Brochure sections are identified for your reference.)

Basic Option

DOCTOR’S OFFICE VISIT PREFERRED PROVIDER

Physician’s charge $250

Our allowance $100

We pay Our allowance minus copayment: $75

Your copayment $25

Plus any difference up to the provider’s charge $0

TOTAL YOU PAY $25

Network Providers

EXAMPLE OF YOUR COSTS WHEN YOU USE PREFERRED PROVIDERS

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52014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary4

Standard Option

* When you use Non-preferred hospitals/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 2014 Blue Cross and Blue Shield Service Benefit Plan brochure.

**Subject to one $350 deductible per member per calendar year; $700 family limit each calendar year.

2014 Standard Option Benefits At-A-GlanceCertain cost sharing amounts do not apply if Medicare is your primary coverage for medical services (it pays first). Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for more information. (Brochure sections are identified for your reference.)

More network providers means more choices. Our

nationwide network of almost one million hospitals,

physicians, pharmacies and other healthcare 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.

More Choices

WHAT YOU PAYSERVICES 2014 STANDARD OPTION

PPO BENEFIT2014 STANDARD OPTION NON-PPO BENEFIT*

PREVENTIVE CARE — 5(a) AND 5(h)

Preventive screenings and related office visit charge; routine physical exams

Nothing for an annual physical and covered preventive screenings

35% of the Plan allowance**

Preventive care for children, up to age 22 Nothing for covered services 35% of the Plan allowance**

Routine dental care Your out-of-pocket expenses are limited to the balance after our payment up to the Maximum Allowable Charge

You are responsible for the balance after our payment, up to the billed charge

PHYSICIAN CARE — 5(a) AND 5(b)

Surgical Care 15% of the Plan allowance** 35% of the Plan allowance**

Office visits, consultations and second surgical opinions

$20 per visit copayment for primary care provider

$30 per visit copayment for specialists

35% of the Plan allowance**

MATERNITY CARE — 5(a)

Inpatient/Outpatient hospital care (Precertification is not required for normal delivery)

No out-of-pocket expenses for covered services

$350 per admission copayment plus 35% of the Plan allowance

Physician Care No out-of-pocket expenses for covered services

35% of the Plan allowance**

HOSPITAL/FACILITY CARE — 5(c)

Inpatient hospital/facility care Precertification is required

$250 per admission copayment for unlimited days

$350 per admission copayment plus 35% of the Plan allowance

Outpatient hospital/facility care 15% of the Plan allowance** 35% of the Plan allowance**

ACCIDENTAL INJURY/MEDICAL EMERGENCY — 5(d)

Accidental injury within 72 hours of accident Nothing for covered services Nothing for covered services; you pay any difference between our allowance and billed charges

Medical emergency/facility care Emergency room: 15% of the Plan allowance**

Urgent care center: $40 copayment

Emergency room: 15% of the Plan allowance**

Urgent care center: 35% of the Plan allowance**

Medical emergency/professional care $20 per visit copayment for primary care provider

$30 per visit copayment for specialists

35% of the Plan allowance**

OTHER BENEFITS — 4

Catastrophic Benefits 100% payment level begins after you pay $5,000 (Self Only) or $6,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses

100% payment level begins after you pay $7,000 (Self Only) and $8,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses

DIAGNOSTIC TEST (SUCH AS AN X-RAY OR BLOOD WORK)

PREFERRED PROVIDER

PARTICIPATING PROVIDER

NON-PARTICIPATING PROVIDER

Physician’s charge $250 $250 $250

Plan allowance $100 $100 $100

We pay 85% of the Plan allowance or $85 65% of the Plan allowance or $65 65% of the Plan allowance or $65

Your coinsurance 15% of the Plan allowance or $15 35% of the Plan allowance or $35 35% of the Plan allowance or $35

Plus any difference up to the provider’s charge $0 $0 $150

YOUR TOTAL ESTIMATED PAYMENT $15 $35 $185

EXAMPLE OF YOUR SAVINGS WHEN YOU USE PREFERRED PROVIDERS

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6 72014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary

New Health Tools on MyBlue®

All-New Health Tools on MyBlue WebsiteMyBlue features new, mobile Health Tools and

resources—the latest health and wellness information

within easy reach from your computer, smartphone

or tablet. It’s everything you already love about

Blue—but better!

Start Here: Blue Health AssessmentWhat you don’t know can hurt you. Take the redesigned

Blue Health Assessment (BHA) to address health risks

before they become issues. Answer simple questions and

in just 10 minutes receive a clear, concise, personalized

approach to a healthier you. You can even take the BHA

multiple times throughout the year to update your plan

and see your progress. Earn $40 for completing the BHA

in 2014!

Next: Online Health CoachIt’s your own private cheering section! When you work

with the all-new Online Health Coach on your path

to better health, you’ll get suggestions for realistic,

personalized activities to stay on track. Start by taking

the BHA, then earn rewards—up to $35—when you

achieve your exercise, stress management, emotional

health, weight loss and nutrition goals. Get ideas and

encouragement for managing your chronic conditions,

like diabetes, asthma and others.

Anytime: Nurse Line Call, chat online or email the Nurse Line for

reliable health information, anytime day or night.

Visit www.fepblue.org or call 1-888-258-3432 to

get reliable health information from knowledgeable,

registered nurses.

Anytime: Personal Health Record Your all-new Personal Health Record (PHR) gives you

easy access to your health information, making it simple

for you to keep track of your medical history,

appointments and lab results. There’s no need to worry

that you’ve forgotten important health details—your PHR

has you covered. When you complete the BHA and work

with the Online Health Coach, this information is fed to

your PHR. Plus, wherever your smartphone goes, your

PHR goes, too!

Anytime: Benefits Statements Let your Benefits Statements be your benefits assistant!

Find ways to save and see a snapshot of your claims and

your benefits in annual or quarterly time periods—anytime

you need answers, not just when you’re close to your filing

cabinet. Access your statements on your computer,

smartphone or tablet—from home, the doctor’s office or

pharmacy. Starting February 2014, you can contact

1-888-258-3432 to request paper statements.

Anytime: Online Symptom Checker Use the Online Symptom Checker to receive possible

reasons for your symptoms*—from your computer,

smartphone or tablet. If you have questions while using

the Online Symptom Checker, you can chat online with

the Nurse Line, too!

*Seek immediate medical attention for life-threatening health issues.

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The Blue Cross and Blue Shield Service Benefit Plan is

introducing new Health Tools powered by WebMD, one

of the most trusted healthcare brands in the U.S. Starting

January 1, 2014, you’ll have new and improved wellness

tools and resources available on the MyBlue website.

Imagine simple, private and smart tools and resources that

you can securely access anytime, anywhere—on your

computer, tablet or smartphone:

• Share your test results with a new doctor—in her office.

• Tell the pharmacist the dosage of your partner’s prescription—at the pharmacy.

• Access activities, challenges and trackers to help you achieve your health goals—from the gym, your home or the office.

• Chat online about your baby’s fever and sleep patterns with a nurse—on a Sunday morning.

• Organize and clear your filing cabinet of all your family’s health claims—even at midnight.

• Enter your symptoms and receive possible reasons for why you have that nagging cough—from the comfort of your home.

Our tools offer support that’s motivational and realistic to

help you where and when you need it.

Your data is secure. The Service Benefit Plan and WebMD

take the safety and security of your health information

very seriously. All of our systems operate in accordance

with federal privacy laws, and we take every effort to

protect your privacy when you use any of our online tools

and resources.

New year, new start! Blue has you covered!

92014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary

Diabetes Management Incentive ProgramThe 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 the BHA and indicate

you have diabetes. This program is limited to two adult

members if you have family coverage.

You will receive credit on your MyBlue Wellness Card

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 MyBlue Wellness Card for

completing additional activities under this incentive.

Tobacco Cessation Incentive ProgramIf you are ready to stop using tobacco, we have the

support you need for success. Take the BHA and indicate

that you use tobacco and then use the Online Health

Coach to select the tobacco cessation goal and create a

plan to quit. After you complete these steps, you’ll be

eligible to receive tobacco cessation products for free.

Both prescription and over-the-counter (OTC) tobacco

cessation products obtained from a Preferred retail

pharmacy are included in this program for Standard

Option and Basic Option members age 18 or older.

When you use a Preferred retail pharmacy to get certain

prescription tobacco cessation medications, we will

waive the cost share. In addition, we will provide benefits

in full for specific OTC tobacco cessation medications

when you purchase the medications at a Preferred retail

pharmacy and have a doctor’s prescription.

EARN WHEN YOU

$20Have A1c tests performed by a covered provider, maximum of two per year, $10 each

$10 Report A1c levels, maximum of two per year, $5 each

$40Purchase diabetic glucose test strips through our Retail or Mail Service Pharmacy, maximum of four per year, $10 each

$10 Have a diabetic foot exam from a covered provider, maximum of one per year, $10

$20

Complete one of the following activities:• $20 for enrolling in a diabetic disease

management program, one per year, OR

• $20 for a diabetic education visit to a covered provider, one per year, OR

• $5 each for completing web-based diabetes education quizzes on our website, up to four per year

$75 Total Maximum Credit

MyBlue® Wellness CardThe MyBlue Wellness Card is a pre-paid card we use to

reward our members for taking charge of their health.

The card is available to members who complete specific

activities to improve their health and may be used to pay

for qualified medical expenses.

Please note: For members who received a MyBlue

Wellness Card in 2011-2013, any new credits will be

applied to your existing card.

Wellness Incentive Program: Blue Health Assessment (BHA) and Online Health Coach Complete the BHA for 2014 to receive $40 on your

MyBlue Wellness Card. Members must be 18 years of age

or older to be eligible for the incentive. Family contracts

are eligible to receive two $40 cards when two adult

members complete the BHA.

After you take the BHA, if you need help reaching your

health and wellness goals or maybe just a push in the

right direction, the Online Health Coach is there for you.

You can set and work toward any number of goals that

you choose in a variety of areas.

You may also receive up to an additional $35 on your

MyBlue Wellness Card for achieving goals related to

a healthy lifestyle in the areas of exercise, nutrition,

stress, weight management and emotional health.

After completing the BHA, you may choose to complete

goals in any of these five areas, up to a maximum

of three goals per calendar year to earn a reward.

When you achieve your first goal, you will receive $15

on your card. For the second and third goals, you will

receive $10 on your card for each one. All three goals

must be completed during the calendar year to earn

the reward.

Extra Motivation!Take steps toward better health and earn up to $75*

Up to two adult-covered family members can each earn up to $75 after completing all four steps.

* Incentive rewards are added to your MyBlue Wellness Card to pay for

qualified medical expenses.

** Goals must be started and completed within the calendar year.

Reward Programs

More benefits. More peace of mind.

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EARN WHEN YOU

$40 Complete the Blue Health Assessment

$15 Achieve your first goal with the Online Health Coach**

$10 Achieve your second goal with the Online Health Coach**

$10 Achieve your third goal with the Online Health Coach**

10 112014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary

Blue ExtrasHealth Club Membership You pay a $25 initiation fee and $25 monthly for

unlimited visits to over 8,000 fitness facilities nationwide.

You are not limited to a specific facility.

For more information, go to www.fepblue.org.

Other Programs• WalkingWorks® is a good start for any exercise routine

with a free pedometer and online walking guide.

Visit www.fepblue.org for more information.

• Blue365® offers access to information, discounts and

savings that make it easier and more affordable to

make healthy choices. For more information, go to

www.fepblue.org.

• Our Vision Care Affinity Program provides savings on

routine eye exams, frames, lenses, contact lenses and

laser vision correction when you use a network

provider. Visit www.fepblue.org for additional

information about this program or call 1-800-551-3337.

• 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 Customer eServiceMyBlue 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.

Visit www.fepblue.org for more information.

Online Explanation of BenefitsYou can decide to go paperless and access your

Explanation of Benefits (EOB) online through MyBlue

Customer eService. You can see and print information

about claims processed for you and your family.

It is easy to opt in to paperless EOBs. Sign on to

www.fepblue.org/myblue.

Finding CareNational Doctor and Hospital Finder Our directory of Preferred providers gives you

the control to choose your healthcare providers

while saving you money on medical costs

through our negotiated discounted rates.

Visit www.fepblue.org/provider for details.

With the Blue Finder smartphone app, finding a

doctor or hospital has never been easier! One tap

with the Blue Finder app connects you to the closest

provider, hospital, or urgent care center. You can dial

a provider’s phone number and use the interactive GPS

map and driving directions to get to your selected

location. Text and email options allow you to share

and save your results.

Blue Distinction Centers®The hospital you select can have a direct impact on

the care you receive and your procedure results, but

finding the right hospital can sometimes be challenging.

You deserve peace of mind when making important

healthcare decisions with your doctor. That’s why we

developed the Blue Distinction Centers recognition

program to identify hospitals with proven expertise in

delivering specialty care.

Blue Distinction Centers and Blue Distinction Centers+

are available nationwide no matter where you work,

live or travel—and finding one is easy. Visit the Blue

Distinction Center Finder at www.bcbs.com/bdcfinder.

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132014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary12

Mail Service Pharmacy Program—Standard Option Only The Mail Service Pharmacy Program for Standard

Option is an easy way to get medications you take

regularly for a chronic condition with the convenience

of home delivery.

If you have any questions about the Mail Service

Pharmacy Program or want to talk to a pharmacist about

your medications, you can call 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 on www.fepblue.org or by

calling 1-800-262-7890. You can also ask your doctor

to order a prescription for you by calling this number

and pressing Option 3.

3. All medications and instructions are sent via U.S.

Postal Service, except medications that require

overnight shipping. You should receive your

prescription within two weeks from the time

you mail in your order.

4. You can order refills by returning the refill slip by mail,

ordering online at www.fepblue.org under Pharmacy

to request the refill or by calling 1-877-337-3455

24 hours a day, seven days a week.

Retail Pharmacy Program— Both OptionsBasic Option members must use a Preferred retail

pharmacy to obtain medications. Standard Option

members can use any Preferred or Non-preferred retail

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% of the

Average Wholesale Price, plus any difference between

our allowance and the billed amount.

Just show your Blue Cross and Blue Shield 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 Preferred 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. You can locate a Preferred retail

pharmacy near you by calling 1-800-624-5060 or by

visiting the Pharmacy section on www.fepblue.org.

Pharmacy Programs

WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS

BENEFIT 2014 STANDARD OPTION COVERAGE 2014 BASIC OPTION COVERAGE

PRESCRIPTION DRUGS

Mail Service Pharmacy Tier 1 (generics)*: $15 copaymentTier 2 (Preferred brand name): $80 copaymentTier 3 (Non-preferred brand name): $105 copaymentCovers 22-90-day supply

Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs

Not a benefit

Preferred Retail Pharmacy Program

Tier 1 (generics)*: 20% coinsuranceTier 2 (Preferred brand name): 30% coinsuranceTier 3 (Non-preferred brand name): 45% coinsurance

Covers up to a 90-day supply

Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs when you use a Preferred PharmacyTier 4 (Preferred specialty drugs): 30% coinsurance

Tier 5 (Non-preferred specialty drugs): 30% coinsurance

Tier 4 and 5 speciality drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.

Tier 1 (generics): $10 copaymentTier 2 (Preferred brand name): $45 copaymentTier 3 (Non-preferred brand name): 50% coinsurance with a $55 minimum

Covers 30-day supply, up to 90-day supply for additional copaymentsTier 4 (Preferred specialty drugs): $60 copayment (30-day supply)

Tier 5 (Non-preferred specialty drugs): $80 copayment (30-day supply)

Tier 4 and 5 speciality drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.

Specialty Pharmacy Program Tier 4 (Preferred specialty drugs): $35 copayment (30-day supply); $95 copayment (90-day supply)

Tier 5 (Non-preferred specialty drugs): $55 copayment (30-day supply); $155 copayment (90-day supply)

90-day supply can only be obtained after 3rd fill

Tier 4 (Preferred specialty drugs): $50 copayment (30-day supply); $140 copayment (90-day supply)

Tier 5 (Non-preferred specialty drugs): $70 copayment (30-day supply); $195 copayment (90-day supply)

90-day supply can only be obtained after 3rd fill

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SCertain prescription drugs require prior approval.*Benefits for generic prescription drugs are different if you have Medicare Part B as your primary coverage.

152014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary

When You Live or Travel OverseasIf 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.

Worldwide Assistance CenterThe Worldwide Assistance Center offers help when

you are traveling outside the U.S., Puerto Rico and the

U.S. 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. You can

call the Center collect at 1-804-673-1678 or email

fepoverseas@axa-assistance.us for help.

How Benefits Work OverseasInpatient Hospital Care: Under both options, benefits

are paid at the Preferred level. Precertification is not

required for hospital admissions outside the U.S.

Outpatient Hospital Care: Benefits under Standard

and Basic Option are paid at the Preferred level.

Physician Care: Benefits for physician care and

care by other covered professional providers

performed outside the U.S. are paid at the Preferred

level using an Overseas Fee Schedule or a provider

negotiated amount.

Prescription Drugs: Drugs that require a prescription

overseas may differ from those that require a

prescription in the U.S. Drugs purchased outside

the U.S. must be an equivalent product that by U.S.

federal law that requires a prescription for purchase in

the U.S., 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 Program if your

address has a U.S. zip code and the prescribing

physician is licensed in the U.S.

• For both Standard and Basic Option, if you purchase

a prescription drug at a local pharmacy outside

the U.S., you pay for the drug and then file a claim

for reimbursement. Payment will be made at the

Preferred level.

14

Filing ClaimsMembers can mail claims to us, fax them to us or submit

claims for medical care performed and prescription

drugs purchased overseas through the MyBlue portal

on www.fepblue.org. For information about mailing

and faxing claims to us, see Section 5(i) in the 2014

Blue Cross and Blue Shield Service Benefit Plan brochure.

To submit your claims electronically:

1. Go to the 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, under Overseas,

select Submit an Overseas claim 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 U.S. dollars. Just complete Section 6 of

the online overseas medical claim form to select wire

payments and the currency you prefer.

Payments by check 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 in U.S. dollars.

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Please note that for overseas countries with laws restricting the importation of prescription drugs from any other country, we are unable to ship drugs from our Mail Service Pharmacy Program to Standard Option members living overseas or from our Specialty Pharmacy Program to Standard or Basic Option members living overseas, even when a valid APO or FPO address is available. You may continue to obtain your prescription drugs from a local overseas pharmacy and submit a claim to us for reimbursement by faxing it to 001-480-614-7674 or filing it via our website at www.fepblue.org/myblue.

16 172014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan Summary

2014 Standard & Basic Option Blue Cross and Blue Shield Service Benefit Plan ComparisonCertain deductibles, copayments and coinsurance amounts do not apply if Medicare is your primary coverage for medical services (it pays first).

WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS

BENEFIT 2014 STANDARD OPTION COVERAGE* 2014 BASIC OPTION COVERAGE**

PHYSICIAN CARE

Office visits and outpatient consultations

$20 per visit copayment for primary care provider$30 per visit copayment for specialists

$25 per visit copayment for primary care provider$35 per visit copayment for specialists

Routine exams and other preventive care services

Nothing for covered services Nothing for covered services

Surgical services Prior approval is required for certain surgical services

15% of the Plan allowanceSubject to calendar year deductible

$150 copayment per performing surgeon in an office setting$200 copayment per performing surgeon in another setting

HOSPITAL/FACILITY CARE

Hospital inpatientPrecertification is required

$250 per admission copayment for unlimited days $175 per day up to $875 per admission for unlimited days

Outpatient hospital/facility care 15% of the Plan allowanceSubject to calendar year deductible

$100 per day facility copayment

PRESCRIPTION DRUGSCertain prescription drugs require prior approval.

Mail Service Pharmacy Program Tier 1 (generics)***: $15 copaymentTier 2 (Preferred brand name): $80 copaymentTier 3 (Non-preferred brand name): $105 copaymentCovers 22-90 day supplyNothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs

Not a benefit

Preferred Retail Pharmacy Program Tier 1 (generics)***: 20% coinsuranceTier 2 (Preferred brand name): 30% coinsuranceTier 3 (Non-preferred brand name): 45% coinsuranceCovers up to a 90-day supplyNothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs when you use a Preferred PharmacyTier 4 (Preferred specialty drugs): 30% coinsuranceTier 5 (Non-preferred specialty drugs): 30% coinsuranceTier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.

Tier 1 (generics): $10 copaymentTier 2 (Preferred brand name): $45 copaymentTier 3 (Non-preferred brand name): 50% coinsurance with a $55 minimumCovers 30-day supply, up to 90-day supply for additional copaymentsTier 4 (Preferred specialty drugs): $60 copayment (30-day supply)Tier 5 (Non-preferred specialty drugs): $80 copayment (30-day supply)Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Pharmacy Program.

Specialty Pharmacy Program Tier 4 (Preferred specialty drugs): $35 copayment (30-day supply); $95 copayment (90-day supply)Tier 5 (Non-preferred specialty drugs): $55 copayment (30-day supply); $155 copayment (90-day supply)90-day supply can only be obtained after 3rd fill

Tier 4 (Preferred specialty drugs): $50 copayment (30-day supply); $140 copayment (90-day supply)Tier 5 (Non-preferred specialty drugs): $70 copayment (30-day supply); $195 copayment (90-day supply)90-day supply can only be obtained after 3rd fill

* When you use Non-preferred hospitals/facilities and professionals, your out-of-pocket expenses are greater. Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan 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 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for complete details.

WHAT YOU PAY WHEN YOU USE PREFERRED PROVIDERS

BENEFIT 2014 STANDARD OPTION COVERAGE* 2014 BASIC OPTION COVERAGE**

LAB, X-RAY AND OTHER DIAGNOSTIC SERVICES

Diagnostic test (X-ray, blood work)Imaging (CT/PET scans, MRIs)

15% of the Plan allowanceSubject to calendar year deductible

$0 copayment for laboratory tests, pathology services and EKGs$40 copayment for diagnostic tests such as EEGs, ultrasounds and X-rays$100 copayment for bone density tests, sleep studies, CT scans, MRIs, PET scans, angiography, genetic testing and nuclear medicine at a professional provider; $150 copayment at a hospital

EMERGENCY CARE

Accidental injury

Medical emergency

Accidental injury: Nothing for outpatient, hospital and physician services within 72 hoursMedical emergency: Regular benefits for physician and hospital care (Subject to calendar year deductible); $40 copayment for urgent care center

Accidental injury and medical emergency:$125 copayment for emergency room care$50 copayment for urgent care centerRegular benefits for physician care

MATERNITY CARE

Inpatient/Outpatient hospital care Precertification is not required for normal deliveryPhysician care

Inpatient/Outpatient hospital care: No out-of-pocket expenses for covered services

Physician care including delivery and pre and postnatal care: No out-of-pocket expenses for covered services

Inpatient/Outpatient hospital care: $175 copayment per inpatient admission; No out-of-pocket expenses for outpatient covered servicesPhysician care including delivery and pre and postnatal care: No out-of-pocket expenses for covered services

DENTAL CARE

Routine dental care Up to age 13: The difference between $12 and the Maximum Allowable Charge (MAC)Age 13 and over: The difference between $8 and the MAC

$25 copayment per evaluation up to 2 per calendar yearPreventive care only

CHIROPRACTIC/OSTEOPATHIC MANIPULATIVE TREATMENT

Manipulative treatment $20 per visit copayment up to 12 manipulations per year $25 per visit copayment up to 20 manipulations per year

OTHER BENEFITS

Catastrophic benefits 100% payment level begins after you pay $5,000 (Self Only) or $6,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses with Preferred providers

100% payment level begins after you pay $5,500 (Self Only) or $7,000 (Self and Family) out-of-pocket in eligible coinsurance and copayment expenses

* When you use Non-preferred hospital/facilities and professionals, your out-of-pocket expenses are greater. Please see the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure for details.** Basic Option does not generally provide benefits for services rendered by Non-preferred providers.

The 2014 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 in this pamphlet.

You can access and download a copy of our 2014 brochure at www.fepblue.org.

As You Make Your Open Season Choices

Open Season DatesThe 2013 Open Season for health insurance changes runs from Monday, November 11, 2013, through Monday, December 9, 2013.

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.

This is a summary of the features for 2014 Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the 2014 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005). All benefits are subject to the definitions, limitations and exclusions set forth in the 2014 brochure.

Please visit our web site www.fepblue.org for more information about your Service Benefit Plan coverage.

AskBlue for Federal Employees

Do you ever wonder if your current option is still the right one for you

and your family? AskBlue is designed to help you make this type of

decision about your health insurance coverage. It is a personal guide

that is simple and provides straightforward answers to your health

insurance choice questions. Visit askblue.fepblue.org.

TYPE OF ENROLLMENT BIWEEKLY MONTHLY BIWEEKLY

Standard Option Self Only (104) $87.82 $190.28 $65.96

Standard Option Family (105) $204.98 $444.12 $156.36

Basic Option Self Only (111) $60.96 $132.09 $40.24

Basic Option Family (112) $142.75 $309.30 $94.22

2014 Premiums and Rates

NON-POSTAL PREMIUM2014 Premiums—Your Share POSTAL PREMIUM

Category 1 Category 2

$79.62

$186.75

$53.04

$124.20