Here are coverage changes to FEP Service Benefit Plan for 2018

Below is an overview of updates to the 2018 Federal Employee Program^® benefit plan.

Skilled nursing facility coverage — Standard Option only
We now provide benefits for skilled nursing facility admissions for members who don’t have Medicare Part A as their primary payor and have selected the Standard Option benefit coverage. Consent for case management must be signed before admission. Previously, benefits were limited to Standard Option members with primary Medicare Part A.

Residential treatment center coverage
We now require precertification for overseas admission to a residential treatment center. Benefits aren’t available if precertification isn’t obtained before admission. Previously, precertification wasn’t required.

Overseas admission changes
We now provide 100 percent coverage for inpatient services performed at a Preferred facility for overseas members when AXA Assistance has arranged direct billing or acceptance of a guarantee of benefits with the facility, and for services billed by a Department of Defense facility. Previously, member cost share wasn’t waived for services billed by a DoD facility.

Telehealth coverage
We now provide benefits for telehealth services delivered via phone or secure online video for the treatment of minor acute conditions, and counseling for behavioral health and substance use disorders.

Member incentive program changes

• The contract holder and spouse are eligible for the wellness incentive rewards for the Blue Health Assessment, Diabetes Management Incentive Program, Hypertension Management Program, Pregnancy Care Incentive Program, and Smoking and Tobacco Cessation Program. Previously, eligible members for the wellness incentive rewards were limited to two adults per contract, age 18 or older.
• Members are now entitled to receive the pregnancy care incentive of $75 toward their health account and the MyBlue Pregnancy Box when they complete the Blue Health Assessment indicating that they are pregnant and submit a copy of the provider’s medical record documenting the first trimester prenatal care visit. Previously, members had to complete the BHA and enroll in My Pregnancy Care Assistant.

Service allowances changes

• We now use the Local Plan Allowance as our plan allowance for inpatient services performed by non-member facilities. Previously, our allowance was based on the average amount paid nationally on a per-day basis to contracting and non-contracting facilities for covered room, board and ancillary charges for type of admission.
• We now use the allowance equal to the greater of one of the following:
• The Medicare participating fee schedule amount or the Medicare Part B drug average sale price, or ASP.
• 100 percent of the local plan allowance for services performed by non-participating professional providers. Previously, if there was no Medicare participating fee schedule or local plan UCR amount, our allowance was 60 percent of the billed charge.
• We now apply facility-billed claims for osteopathic and chiropractic manipulative treatment services to a member’s annual manipulative treatment visit maximum. Previously, only professional claims applied to a member’s annual visit maximum.

Human organ transplant coverage

• We now limit the coverage of blood and marrow stem cell transplants for autoimmune diagnoses to those listed on Page 75 of the Service Benefit Plan brochure. Previously, the listed diagnoses were presented as examples of covered diagnoses. Now those listed diagnoses serve as the complete list of covered diagnoses. Benefits aren’t available for diagnoses not on the list.
• We now limit the coverage of allogeneic blood or marrow stem cells to the following inherited metabolic disorders: Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy, Hurler’s syndrome and Maroteaux-Lamy syndrome variants. Previously, we also covered Hunter’s syndrome and Sanfilippo’s syndrome.
• We now provide coverage limited to the following diagnoses for autologous blood or marrow stem cell transplants, only when performed as part of a clinical trial: chronic lymphocytic leukemia/small lymphocytic lymphoma, chronic myelogenous leukemia, glial tumors, retinoblastoma, rhabdomyosarcoma, Wilm’s tumor and other childhood kidney cancers. Previously, we also covered breast cancer and epithelial ovarian cancer under the autologous blood or marrow stem cell clinical trial transplant benefit.

Reimbursement for Medicare Part B premiums — Basic Option only
We now provide a reimbursement account for Medicare Part B premiums to any member with Medicare Part A and Part B and who have selected the Basic Option coverage. The account must be used exclusively to pay Medicare Part B premiums. Previously, there was no reimbursement account benefit.

Screening coverage changes

• We now provide preventive care benefits for DNA analysis of stool samples as a technique for colorectal cancer screening, paid in full when billed by a preferred provider. Limited to one per calendar year. Previously, medical benefits were provided with a member cost share.
• We now provide preventive care benefits for the screening of latent tuberculosis infection in adults age 18 and older. Limited to once per calendar year. Previously, no preventive care benefits were available for this screening.

Family planning coverage
We now provide family planning benefits for vasectomy and related covered professional services, e.g., anesthesia, with no member cost share. Previously, this was a surgical benefit with member cost share.

Prescription drug benefit changes

• Standard Option prescription drug benefit changes
• Copayment for Tier 1 (generic) anti-hypertensive drugs obtained at Preferred retail pharmacies is now $3 (no deductible). Previously, cost share under Preferred retail pharmacies was 20 percent of the plan allowance (no deductible).
• Copayment for Tier 1 (generic) anti-hypertensive drugs obtained through the Mail Service Prescription Drug Program is now $3 (no deductible). Previously, copayment for the Mail Service Prescription Drug Program was $15 (no deductible).
• Copayment for Tier 2 preferred brand-name asthma drugs obtained at Preferred retail pharmacies is now 20 percent of the plan allowance (no deductible). Previously, copayment was 30 percent of the plan allowance (no deductible).
• Copayment for Tier 2 preferred brand-name asthma drugs obtained through the Mail Service Prescription Drug Program is now $65 (no deductible). Previously, copayment was $80 (no deductible).
• Cost share for Tier 3 non-preferred brand-name drugs is 50 percent (no deductible) of the plan allowance for Preferred retail pharmacies. Previously, cost share was 45 percent (no deductible) of the plan allowance.
• Copayment for Tier 3 non-preferred brand-name drugs will be $125 (no deductible) for the Mail Service Prescription Drug Program. Previously, copayment was $105.

• Basic Option prescription drug benefit changes
• Copayment for Tier 1 (generic) anti-hypertensive drugs obtained at Preferred retail pharmacies is now $5. Previously, cost share under Preferred retail pharmacies was $10 copayment for 30-day supply.
• When Medicare Part B is primary, copayment for Tier 1 (generic) anti-hypertensive drugs obtained through the Mail Service Prescription Drug Program is now $5. Previously, copayment for the Mail Service Prescription Drug Program was $20.
• Copayment for Tier 2 preferred brand-name asthma drugs obtained at a Preferred retail pharmacy is now $35 for each purchase of up to a 30-day supply ($105 copayment for a 90-day supply). Previously, copayment was $50 for each purchase of up to a 30-day supply ($150 copayment for 90-day supply).
• When Medicare Part B is primary, copayment for Tier 2 preferred brand-name asthma drugs obtained at a Preferred retail pharmacy is now $30 for each purchase of up to a 30-day supply ($90 copayment for a 90-day supply). Previously, copayment was $45 for each purchase up to a 30-day supply ($135 copayment for 90-day supply).
• When Medicare Part B is primary, copayment for Tier 2 preferred brand-name asthma drugs obtained through the Mail Service Prescription Drug Program is now a $75 copayment. Previously, copayment was $90.
• Cost share for Tier 3 non-preferred brand-name drugs obtained at a Preferred retail pharmacy is 60 percent of plan allowance ($75 minimum) for up to a 30-day supply ($210 minimum for a 90-day supply). Previously, cost share was 60 percent of the plan allowance ($65 minimum) for a 30-day supply ($195 minimum for a 90-day supply).
• When Medicare Part B is primary, cost share for Tier 3 non-preferred brand-name drugs obtained at a Preferred retail pharmacy is 50 percent of the plan allowance ($60 minimum) for up to a 30-day supply ($175 minimum for a 90-day supply). Previously, cost share was 50 percent of the plan allowance ($55 minimum) for a 30-day supply ($165 minimum for a 90-day supply).
• When Medicare Part B is primary, cost share for Tier 3 non-preferred brand-name drugs obtained through the Mail Service Prescription Drug Program is now a $125 copayment. Previously, copayment was $115.

• Standard and Basic Options prescription drug benefit changes
• Copayment for Tier 1 (generic) asthma drugs is now $5 for Preferred retail pharmacies and Mail Service Prescription Drug Program (with and without Medicare Part B). Previously, cost share was 20 percent of the plan allowance (no deductible) for Standard Option and $10 copayment for each purchase of up to a 30-day supply and a $30 copayment for 90-day supply for Basic Option.
• We now provide preventive care benefits for generic cholesterol-lowering statin drugs. Previously, pharmacy benefits were provided with a member cost share.
• We now provide preventive care benefits for aspirin to prevent cardiovascular disease and colorectal cancer for adults ages 50 through 59.
• If member chooses to get the brand-name drug and provider’s prescription allows for generic substitution, applicable cost share for a brand-name drug will be the drug tier cost share plus the difference in the costs of the brand-name and generic drugs. Member expenses for “dispense as written” prescriptions don’t count toward catastrophic protection out-of-pocket maximum. Previously, if the provider’s prescription allowed for generic substitution and member chose to get the brand-name drug, they were responsible only for the drug tier cost share.
• We now provide benefits for oral medical foods under the pharmacy benefit only. Prior approval is required. Previously, medical benefits were provided for oral medical foods.
• We now provide benefits for gonadotropin-releasing hormone antagonists and testosterones regardless of age. Previously, benefits were limited to members age 16 and older.

The enrollment codes for 2018 remain the same

For more information on FEP benefits, refer to the 2018 Blue Cross and Blue Shield Service Benefit Plan. If you have questions, call our Customer Service line at 1-800-482-3600.