New for 2019: FEP Blue Focus

The Blue Cross and Blue Shield Federal Employee Program^® has a new benefit option for 2019 — FEP Blue Focus. This is a fee-for-service plan that provides covered services through a Preferred Provider Organization. Members can choose their own health care providers without referrals but must use Preferred providers to receive benefits.

Benefits under FEP Blue Focus have been divided into three categories:

Core Benefits are those that have a low copayment or none at all and aren’t subject to a deductible or coinsurance. These are benefits commonly used for general care and to cover accidental injuries.

For example, each member’s first 10 health care visits with a primary care physician, specialist or other health care professional are subject to a $10 copayment per visit. Preventive care benefits for adults and children are covered at no cost to the member.

Non-Core Benefits are for unexpected medical costs incurred during the calendar year. They share the same annual deductible and coinsurance level. For example, after a member has 10 health care visits, he or she will pay a coinsurance for additional visits until the deductible is reached.

Wrap Benefits may or may not be used during the year. These benefits are subject to limitations and different copayments or coinsurance levels than the Core and Non-Core benefits.

For example, the calendar-year deductible doesn’t apply to the following:

Occupational therapy
Physical or speech therapy
Maternity care benefits

Occupational, physical or speech therapy services have a $25 copayment per visit and are limited to 25 visits per person, per calendar year for the individual therapy or any combination of all three therapies.

Maternity facility care has a $1,500 copayment per pregnancy. Members who become pregnant during the benefit period are encouraged to contact Blue Cross Blue Shield of Michigan during the first trimester.

Prior approval required

Some services and procedures covered under FEP Blue Focus require prior approval, such as CT scans and MRIs, genetic testing and certain surgeries. Failure to obtain the prior approval may result in a $100 penalty to the member.

Inpatient admissions require precertification. Failure to obtain precertification, may result in a $500 penalty to the member.

For more information on prior approvals or precertification, download the FEP Blue Focus brochure at fepblue.org/brochure or contact Customer Service at 1-800-482-3600.

The FEP Blue Focus benefit plan uses a two-tiered closed formulary.

Preferred retail pharmacy – Tier 1: (Preferred generic drugs at a Preferred retail pharmacy)

$5 for up to a 30-day supply
$15 for up to a 90-day supply

Preferred retail pharmacy – Tier 2 (Preferred brand-name drugs)

40% of the plan allowance (up to $350 maximum) for up to a 30-day supply

40% of the plan allowance (up to a $1,050 maximum) for up to a 90-day supply

Specialty pharmacy – Tier 2 (Preferred generic specialty drugs and Preferred brand-name specialty drugs)

40% of the Plan allowance (up to a $350 maximum) for up to a 30-day supply

Members must obtain prior approval for certain drugs and supplies, and prior approval must be renewed periodically. Preferred retail pharmacies or the Specialty Drug Pharmacy Program must be used to receive benefits. To view the formulary, go to fepblue.org/formulary.

For information about FEP pharmacy benefits, contact CVS Caremark^® at 1-800-624-5060 or go to fepblue.org/pharmacy.

Know what’s covered

FEP Blue Focus offers extensive benefits, but it doesn’t cover everything. It’s important to know what isn’t included.

Services FEP Blue Focus doesn’t cover include:

Routine dental services
Non-preferred drugs
Hearing aids
Skilled nursing facility
Long-term care

To see a complete list of exclusions, see the FEP Blue Focus brochure at fepblue.org/brochure.

For an official statement of benefits, see the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus brochure (RI 71-017). All benefits are subject to the definitions, limitations and exclusions set forth in the brochure.

For more information on FEP Blue Focus, go to fepblue.org or contact Customer Service at 1-800-482-3600.

CVS Caremark^® is an independent company that provides pharmacy benefit management services.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.