2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5. FEP Blue Focus Overview
Page 34
Section 5. FEP Blue Focus Overview
Page 34
Section 5. FEP Blue Focus Overview
The benefit package for FEP® Blue Focus is described in Section 5, which is divided into subsections 5(a) through 5(i).
Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about FEP Blue Focus benefits, contact us at the customer service phone number on the back of your ID card or go to our website at www.fepblue.org.
We have provided a new way for you to consider the benefits available to you under FEP Blue Focus to determine whether this product will be a good choice for you and your family. We have divided the benefits under FEP Blue Focus into three basic categories: CORE, NON-CORE and WRAP. The following information describes the portion you pay, based on the benefits you use. All benefits are subject to the definitions, limitations, and exclusions in this brochure. In the following charts, we summarize specific expenses we cover; for more detail, look inside. Do not rely on the charts alone. Note: For more information about services received overseas, see Section 5(i).
The “CORE” benefits are those under this program that form the most important level – the base of the program. These benefits have only a low or no copayment and are not subject to a deductible or coinsurance for the care received. These benefits are most commonly used to receive general care and to maintain your overall health and well-being, in addition to coverage for accidental injuries. For example, your first 10 healthcare visits with a primary care physician, specialist or other healthcare professional will be subject to a $10 copayment for each visit.
The “NON-CORE” benefits are there to provide coverage for any unexpected medical costs you may incur during the calendar year. These share the same annual deductible and the same co-insurance level (see Annual Cost-Shares below). When the catastrophic out-of-pocket maximum has been satisfied, we pay 100% of the Plan allowance for the remainder of the calendar year (see page 30 for more information). For example, after your first 10 visits (primary care, specialist or other healthcare provider), you will have a deductible to satisfy of $500 and then you will pay 30% of the Plan allowance for the visit. You may or may not have a need to use these benefits during the year.
“WRAP” benefits provide the final layer of protection and complete or “wrap-up” the FEP Blue Focus benefit package. These are benefits you may or may not have a need to use during the year. These benefits have visit limitations and/or different copayments or co-insurance levels than the “CORE” or “NON-CORE” benefit levels. The calendar year deductible does not apply to these benefits.
In addition to the general exclusions found in Section 6, this program does not provide benefits for some services that are covered under the Service Benefit Plan Standard or Basic Options. An example of services excluded under FEP Blue Focus is coverage for routine dental care. See the charts below.
You must use Preferred providers for your care to be eligible for benefits, except in certain circumstances, such as medical emergency or accidental injury services. Preferred providers will submit claims to us on your behalf.
Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about FEP Blue Focus benefits, contact us at the customer service phone number on the back of your ID card or go to our website at www.fepblue.org.
We have provided a new way for you to consider the benefits available to you under FEP Blue Focus to determine whether this product will be a good choice for you and your family. We have divided the benefits under FEP Blue Focus into three basic categories: CORE, NON-CORE and WRAP. The following information describes the portion you pay, based on the benefits you use. All benefits are subject to the definitions, limitations, and exclusions in this brochure. In the following charts, we summarize specific expenses we cover; for more detail, look inside. Do not rely on the charts alone. Note: For more information about services received overseas, see Section 5(i).
The “CORE” benefits are those under this program that form the most important level – the base of the program. These benefits have only a low or no copayment and are not subject to a deductible or coinsurance for the care received. These benefits are most commonly used to receive general care and to maintain your overall health and well-being, in addition to coverage for accidental injuries. For example, your first 10 healthcare visits with a primary care physician, specialist or other healthcare professional will be subject to a $10 copayment for each visit.
The “NON-CORE” benefits are there to provide coverage for any unexpected medical costs you may incur during the calendar year. These share the same annual deductible and the same co-insurance level (see Annual Cost-Shares below). When the catastrophic out-of-pocket maximum has been satisfied, we pay 100% of the Plan allowance for the remainder of the calendar year (see page 30 for more information). For example, after your first 10 visits (primary care, specialist or other healthcare provider), you will have a deductible to satisfy of $500 and then you will pay 30% of the Plan allowance for the visit. You may or may not have a need to use these benefits during the year.
“WRAP” benefits provide the final layer of protection and complete or “wrap-up” the FEP Blue Focus benefit package. These are benefits you may or may not have a need to use during the year. These benefits have visit limitations and/or different copayments or co-insurance levels than the “CORE” or “NON-CORE” benefit levels. The calendar year deductible does not apply to these benefits.
In addition to the general exclusions found in Section 6, this program does not provide benefits for some services that are covered under the Service Benefit Plan Standard or Basic Options. An example of services excluded under FEP Blue Focus is coverage for routine dental care. See the charts below.
You must use Preferred providers for your care to be eligible for benefits, except in certain circumstances, such as medical emergency or accidental injury services. Preferred providers will submit claims to us on your behalf.
ANNUAL COST-SHARES
See above for information about when these cost-shares apply.
Cost-Share: Deductible
Member Responsibility (Self Only): $500
Member Responsibility (Self Plus One/Self and Family): $1,000
Cost-Share: Coinsurance (medical)
Member Responsibility (Self Only): 30% of the Plan Allowance
Member Responsibility (Self Plus One/Self and Family): 30% of the Plan Allowance
Cost-Share: Catastrophic Maximum
Member Responsibility (Self Only): $8,500
Member Responsibility (Self Plus One/Self and Family): $17,000
See above for information about when these cost-shares apply.
Cost-Share: Deductible
Member Responsibility (Self Only): $500
Member Responsibility (Self Plus One/Self and Family): $1,000
Cost-Share: Coinsurance (medical)
Member Responsibility (Self Only): 30% of the Plan Allowance
Member Responsibility (Self Plus One/Self and Family): 30% of the Plan Allowance
Cost-Share: Catastrophic Maximum
Member Responsibility (Self Only): $8,500
Member Responsibility (Self Plus One/Self and Family): $17,000