Foreign Service Benefit Plan: Health Plan Benefits

Summary of Benefits and Coverage for the Foreign Service High Option Benefit Plan - 2013

Review the 2013 Summary of Benefits and Coverage chart.

Please note the chart is only a summary, please refer to the Official Plan Brochure for more details. All benefits are subject to the definitions, limitations and exclusions in the Official Plan Brochure.

Review the Glossary of Health Coverage and Medical Terms.

Summary of Benefits for the High Option of the Foreign Service Benefit Plan - 2013

Please do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in the Official Plan Brochure. On this page, we summarize specific expenses we cover. For more detail, please refer to the Official Plan Brochure.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover of your enrollment form.

Below, an asterisk (*) means the item is subject to the $300 calendar year deductible. And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a non-PPO physician or other health care professional.

Medical Services Provided by Physicians
Topic	You Pay
High Option Benefit	PPO	Non-PPO	Providers outside the 50 United States
Diagnostic and treatment services provided in the hospital and office	10% of our allowance*	30% of our allowance and any difference between our allowance and the billed amount*	10% of our allowance*

Services Provided by a Hospital
Topic	You Pay
High Option Benefit	PPO	Non-PPO	Providers outside the 50 United States
Inpatient	Nothing	$200 per hospital stay and 20% of charges	Nothing
Outpatient - Surgical	10% of our allowance*	30% of our allowance and any difference between our allowance and the billed amount*	10% of our allowance*
Outpatient - Medical	10% of our allowance*	30% of our allowance and any difference between our allowance and the billed amount*	10% of our allowance*

Emergency Benefits
Topic	You Pay
High Option Benefit	PPO	Non-PPO	Providers outside the 50 United States
Accidental injury: emergency room charges (ER) and urgent care facility charges, ER and urgent care physicians' charges and ancillary services (performed at the time of the ER or urgent care facility visit) OR initial office visit and ancillary services (performed at the time of the initial office visit)	Nothing	Only the difference between our allowance and the billed amount	Nothing
Medical emergency	10% of our allowance*	10% of our allowance and any difference between our allowance and the billed amount*	10% of our allowance*
Outpatient care in an urgent care facility because of a medical emergency	$35 copayment per occurrence	$35 copayment per occurrence and any difference between our allowance and the billed amount	$35 copayment per occurrence

Mental Health & Substance Abuse
Topic	You Pay
High Option Benefit	PPO	Non-PPO	Providers outside the 50 United States
Mental health and substance abuse treatment	Regular cost sharing*	Regular cost sharing*	Regular cost sharing*

Prescription Drugs
Topic	You Pay
High Option Benefit	Level I (Generic)	Level II (Single-source Brand Name)	Level III (Multi-source Brand Name)	Level IV (Specialty Drugs)
Retail pharmacy - Network Pharmacies inside the 50 United States Note: You must show your Plan ID card	$10 copay for up to a 30-day supply	25% ($30 minimum) for up to a 30-day supply	30% ($50 minimum) for up to a 30-day supply	25% for up to a 30-day supply (Note: Restrictions apply on refills)
Retail pharmacy - Non-Network Pharmacies inside the 50 United States: 100% and cannot claim reimbursement from the Plan (no deductible)	100%	100%	100%	100%
Retail pharmacy - Retail pharmacies outside the 50 United States: 10% (claim reimbursement from the Plan)	10%	10%	10%	10%
Mail Order (Express Scripts by Mail)	$10 for up to a 90-day supply	$55 for up to a 90-day supply	$70 for up to a 90-day supply	25% up to maximum of $150 for up to a 90-day supply

Dental Care
High Option Benefit	You Pay
Routine preventive care and surgical procedures	The difference between our scheduled allowances and the actual billed amounts
Orthodontics	50% of our allowance up to our maximum payment of $1,000 and 100% after our maximum payment of $1,000

Protection Against Catastrophic Costs
Topic	You Pay
High Option Benefit	PPO	Non-PPO	Providers outside the 50 United States
Protection against catastrophic costs (out-of-pocket maximum) Note: Benefit maximums still apply and some costs do not count toward this protection.	Nothing after $4,000/Self Only or $4,500/Self and Family enrollment per year	Nothing after $6,000/Self Only or $6,500/Self and Family enrollment per year	Nothing after $4,000/Self Only or $4,500/Self and Family enrollment per year