2015 BLUE CROSS AND BLUE SHIELD SERVICE BENEFIT

PLAN & MEDICARE BENEFITS

2015 BLUE CROSS AND BLUE SHIELD SERVICE BENEFIT PLAN & MEDICARE BENEFIT COMPARISONYour Blue Cross and Blue Shield Service Benefit Plan plus Medicare coverage work together to maximize your benefits and minimize your out-of-pocket costs. These tables highlight some of the most commonly used benefits and the amount you will pay when you have Standard or Basic Option, with or without Medicare Parts A and B as your primary carrier(s).

BENEFIT 2015 BASIC OPTION WITH PREFERRED PROVIDERS* 2015 BASIC OPTION WITH PRIMARY MEDICARE A & B AND PREFERRED PROVIDERS

PHYSICIAN CARE

Office visits and outpatient consultations

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

You pay nothing

Routine exams and other preventive care services

Nothing for covered services You pay nothing

Surgical services Prior approval is required for certain surgical services

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

You pay nothing

HOSPITAL/FACILITY CARE

Hospital inpatientPrecertification is required

$175 per day up to $875 per admission for unlimited days You pay nothing

Outpatient hospital/facility care $100 per day per facility copayment You pay nothing

PRESCRIPTION DRUGS Certain prescription drugs require prior approval.

Retail Pharmacy Program

Tier 1 (Generics): $10 copayment Tier 2 (Preferred brand name): $45 copaymentTier 3 (Non-preferred brand name): 50% of the Plan allowance 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.

Tier 1 (Generics): $10 copayment Tier 2 (Preferred brand name): $45 copaymentTier 3 (Non-preferred brand name): 50% of the Plan allowance 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): $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

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

EMERGENCY CARE

Accidental injury and medical emergency

$125 copayment for emergency room care$35 copayment for urgent care centerRegular benefits for physician care

You pay nothing

OTHER BENEFITS

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

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

*Basic Option benefits are not available for services performed by Non-preferred providers except in certain circumstances, such as emergency care.Please see the 2015 Blue Cross and Blue Shield Service Benefit Plan brochure for complete details.

Basic Option

* When you use Non-preferred hospitals/facilities and professionals, your out-of-pocket expenses are greater. **Subject to the calendar year deductible.Please see the 2015 Blue Cross and Blue Shield Service Benefit Plan brochure for complete details.

Standard Option

BENEFIT 2015 STANDARD OPTION WITH PREFERRED PROVIDERS* 2015 STANDARD OPTION WITH PRIMARY MEDICARE A & B

PHYSICIAN CARE

Office visits and outpatient consultations

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

You pay nothing

Routine exams and other preventive care services

Nothing for covered services You pay nothing

Surgical services Prior approval is required for certain surgical services

15% of the Plan allowance** You pay nothing

HOSPITAL/FACILITY CARE

Hospital inpatientPrecertification is required

$250 per admission copayment for unlimited days You pay nothing

Outpatient hospital/facility care 15% of the Plan allowance** You pay nothing

PRESCRIPTION DRUGS Certain prescription drugs require prior approval.

Mail Service Pharmacy Program

Tier 1 (Generics): $15 copayment Tier 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

Tier 1 (Generics): $10 copayment Tier 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

Retail Pharmacy Program

Tier 1 (Generics): 20% of the Plan allowanceTier 2 (Preferred brand name): 30% of the Plan allowanceTier 3 (Non-preferred brand name): 45% of the Plan allowanceCovers 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 retail pharmacyTier 4 (Preferred specialty drugs): 30% of the Plan allowance (30-day supply)Tier 5 (Non-preferred specialty drugs): 30% of the Plan allowance (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.

Tier 1 (Generics): 15% of the Plan allowanceTier 2 (Preferred brand name): 30% of the Plan allowanceTier 3 (Non-preferred brand name): 45% of the Plan allowanceCovers 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 retail pharmacyTier 4 (Preferred specialty drugs): 30% of the Plan allowance (30-day supply)Tier 5 (Non-preferred specialty drugs): 30% of the Plan allowance (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): $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

EMERGENCY CARE

Accidental injury

Medical emergency

Nothing for outpatient, hospital and physician services within 72 hours

Regular benefits for physician and hospital care**; $30 copayment for urgent care center

You pay nothing

You pay nothing

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 $5,000 (Self Only) or $6,000 (Self and Family) out-of-pocket in eligible coinsurance, copayment and deductible expenses with Preferred providers

CALENDAR YEAR DEDUCTIBLE

$350 per person$700 per family

The calendar year deductible is waived

As you approach age 65, you will have to make a

decision about enrolling in Medicare. This decision is

voluntary during specific enrollment periods. If you

don’t sign up when you are first eligible, you may have

to pay a late enrollment penalty.

Medicare Part A (hospital insurance) coverage is available free of charge to people age 65 and older who meet the eligibility requirements necessary to qualify for Social Security benefits. You automatically qualify if you were a federal employee on January 1, 1983. Most people pay a monthly premium for Medicare Part B (medical insurance) coverage.

If you have questions about Medicare benefits or eligibility, call Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048) or visit www.medicare.gov.

When you combine Medicare primary coverage with your Service Benefit Plan coverage, you have peace of mind knowing that most of your medical costs are covered. To help you understand the benefits explained in this brochure, and to understand how benefits are paid without Medicare coverage or when Medicare is secondary because you are still working, the 2015 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005) is available at www.fepblue.org/brochure.

Prescription Drug Coverage The U.S. Office of Personnel Management (OPM) has determined that the Blue Cross and Blue Shield Service Benefit Plan’s prescription drug coverage is, on average, comparable to Medicare Part D prescription drug coverage. Therefore, you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage.

Wellness Incentive ProgramTake steps to better health and earn rewards. Complete the 2015 Blue Health Assessment (BHA) and earn $50 on your MyBlue® Wellness Card to use for qualified medical expenses, such as copayments and prescription costs. After you take the BHA, you can earn up to $35 more on your card by completing three lifestyle goals with the Online Health Coach. In total, you can earn up to $85 on your MyBlue Wellness Card for completing the BHA and three goals with the Online Health Coach in 2015. Up to two adults on a contract are eligible for this incentive. Log in or register at www.fepblue.org/myblue to learn more.

MEDICARE & BLUE

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