Blue Cross and Blue Shield Service Benefit Plan-Basic

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General Information

Plan Name:	Blue Cross and Blue Shield Service Benefit Plan-Basic
Service Area:	Nationwide
Brochure:	PDF Version
Brochure:	Text Version
NCQA Accreditation:	n/a
JCAHO Accreditation:	n/a
URAC Accreditation:	n/a
Plan Type:	FFS
Enrollment Code-Self:	111
Enrollment Code-Self & Family:	112
Link to Plan Home Page:	http://www.fepblue.org
Telephone:	Local phone #

Benefits

	PPO	Non PPO
Deductible Per Person Calendar Year	None
Deductible Per Person-Prescription Drug	None
Deductible Per Hospital Stay-Inpatient	$100/day;$500
Copay Coinsurance Doctors & Outpatient Tests	$20/$30
Copay Coinsurance Hospital Inpatient R & B	Nothing
Copay Coinsurance Hospital Inpatient Other	Nothing
Copay Coinsurance Hospital Outpatient	$30
Copay Coinsurance Prescription Drugs Home Delivery Generic	$10-I
Copay Coinsurance Prescription Drugs Home Delivery Brand Name	$25-I
Copay Coinsurance Prescription Drugs Generic	$10
Copay Coinsurance Prescription Drugs Brand Name	$25
Copay Coinsurance Prescription Drugs Nonformulary	>$35 or 50%

Rates

Non-Postal
Biweekly	Self: $31.61	Self: & Family: $75.74
Monthly	Self: $68.50	Self: & Family: $164.10
Twice Biweekly	Self: $63.22	Self: & Family: $151.48
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Annuitants
Monthly	Self: $68.50	Self: & Family: $164.10
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U.S. Postal Service Employees (Type A)
Biweekly	Self: $14.23	Self: & Family: $35.40
Monthly	Self: $30.82	Self: & Family: $76.70
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U.S. Postal Service Employees (Type B)
Monthly	Self: $37.33	Self: & Family: $138.69
Biweekly	Self: $17.23	Self: & Family: $64.01
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Worker's Compensation Recipients
Twice Biweekly	Self: $63.22	Self: & Family: $151.48
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Certain Temporary Employees
Biweekly	Self: $126.46	Self: & Family: $299.15
Monthly	Self: $274.00	Self: & Family: $648.16
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Former Spouse Enrollees
Monthly	Self: $274.00	Self: & Family: $648.16
Biweekly	Self: $126.46	Self: & Family: $299.15
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Temporary Continuation of Coverage
Biweekly	Self: $128.99	Self: & Family: $305.13
Monthly	Self: $279.48	Self: & Family: $661.12
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FDIC
Biweekly	Self: $14.23	Self: & Family: $35.40
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Department of Defense Demo Project
Monthly	Self: $65.07	Self: & Family: $153.94
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Department of Defense Demo Project Temporary Continuation of Coverage
Monthly	Self: $265.51	Self: & Family: $628.07
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