Federal Employees Program (FEP) - FAQ - Find Help - Arkansas Blue Cross and Blue Shield

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Frequently Asked Questions:
Federal Employees Program (FEP)

For additional information on FEP, visit the Blue Cross and Blue Shield http://www.fepblue.org site.

Medical Benefits

Are preventive physical examinations for adults covered?
What would be my out-of-pocket expense when I am admitted to the hospital for a medical condition?
What is precertification or prenotification, and when is it needed?
Can I get a prior approval for a surgery?
The provider is billing me for the difference between the total bill and what I owe on the explanation of benefits (EOB). What should I do?
What are my ambulance benefits for an accident or medical emergency?
What is my catastrophic-protection, out-of-pocket maximum?
What are my benefits for physical therapy?
What are my benefits for speech and occupational therapy?
What are my benefits for durable medical equipment (DME)?
Do I have benefits to quit smoking?
Are chiropractors covered?
What is Blue Health Connection?

Dental Benefits

Is a root canal or a crown covered by dental benefits?

Vision Benefits

Are routine eye exams covered under the Federal Employee Service Benefit Plan?

Pharmacy Benefits

What type of drug coverage do I have?
Do some prescriptions require prior approval?
Do I have to use the Mail-Order Program?
What is the Discount Vitamin Program?

General

If I have questions about claim status or benefits, whom do I contact?
If I have questions about the Explanation of Benefits (EOB), whom do I contact?
Why didn't I get my premium statement this month?
Why do you want to know if I have other coverage?

Medical Benefits

1. Are preventive physical examinations for adults covered?
Routine screening examinations performed based on the schedule below and performed by a preferred provider with a routine diagnosis can be paid in full after the associated office-visit copayment. The covered routine screening exams are: history and risk assessment, chest x-ray, electrocardiogram (EKG), urinalysis, basic metabolic or comprehensive metabolic panel test, complete blood count (CBC), cholesterol tests and chlamydial infection test. They are covered for members as follows:

Under 65: Once every three consecutive calendar years.
65 and older: Once every calendar year.

Basic Option and Standard Option require a copayment for the office visit.

Note: When the above services are billed with a medical diagnosis, benefits would be eligible under "Other Medical Benefits."

2. What would be my out-of-pocket expense when I am admitted to the hospital for a medical condition?
When you are admitted to the hospital, you will have several different providers that could bill for services (hospital, physician, anesthesiologist, radiologist or pathologist).

3. What is precertification or prenotification, and when is it needed?
Consult your benefit booklet or contact the customer service number on your ID card to determine if you are subject to precertification or prenotification prior to certain medical services.

Precertification is the requirement to contact the local Blue Cross and Blue Shield plan serving the area where the services will be rendered before being admitted to a hospital for inpatient care or within two business days following an emergency hospital admission. It is your responsibility to ensure that precertification is obtained. You, your physician or the hospital must contact our precertification vendor (Access Health) at 1-800-451-7302. If precertification is not obtained and benefits are otherwise payable, benefits for the admission will be reduced by $500.

Precertification is not needed for in-state, in-network inpatient admissions.

Precertification is not needed for maternity admissions unless your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section. Then, you, your physician or the hospital must contact Access Health, the precertification vendor for Arkansas Blue Cross and Blue Shield.

4. Can I get a prior approval for a surgery?
Prior approval is given only for services specifically listed in Section 3 and Section 10 of the Service Benefit Plan brochure.

5. The provider is billing me for the difference between the total bill and what I owe on the explanation of benefits (EOB). What should I do?
Contact the provider's office and inquire why you received a bill. Give the information from the EOB, which indicates what you owe. If there is no resolution between you and the provider, contact FEP Customer Service at 1-800-482-6655 or 501-378-2531.

6. What are my ambulance benefits for an accident or medical emergency?
Standard Option:
Accident
For an ambulance trip due to an accident or within 72 hours of an accident, the Federal Employee Service Benefit Plan (FEP) pays 100 percent of its allowance. (Individual ambulance companies are nonparticipating providers. You will owe the difference between the FEP allowance and the ambulance total charges.)
Medical Emergency
An ambulance trip due to a medical emergency is paid at 75 percent of the FEP allowance. (Most ambulance companies are not preferred or participating providers. You will owe the difference between the FEP allowance and the ambulance total charges.)

Basic Option:
Ambulance trips due to an accident or medical emergency are paid in full after a $50 copayment. You will not owe an additional balance.

7. What is my catastrophic-protection, out-of-pocket maximum?
If the total amount of eligible* out-of-pocket expenses in a calendar year for you and your covered family members meets the following limits, you and any covered family members will not have to continue paying them for the remainder of the calendar year.

Standard Option:
If the total amount of these out-of-pocket expenses from using preferred providers for you and your covered family members exceeds $4,000 in a calendar year, you and any covered family members will not have to pay these expenses for the remainder of the calendar year when you continue to use preferred providers. You will, however, have to pay them when you use nonpreferred providers until your out-of-pocket expense for the services of both preferred and nonpreferred providers reaches $6,000 under Standard Option.

Basic Option:
If the total amount of these eligible* out-of-pocket expenses from using preferred providers for you and your covered family members exceeds $5,000 in a calendar year under Basic Option, you and any covered family members will not have to pay these expenses for the remainder of the calendar year.

*There are some expenses that do not count toward the catastrophic-protection, out-of-pocket maximum, and you must continue to pay them even after your expenses exceed the limits described above. For additional information, refer to the Blue Cross and Blue Shield Service Benefit Plan Web site at http://www.fepblue.org.

8. What are my benefits for physical therapy?
Standard Option:
Physical therapy is limited to 50 visits per calendar year. To receive preferred benefits, go to your preferred hospital. Your out-of-pocket expense will be less. Independent physical therapists are considered nonparticipating. If you choose to go to a physical therapist's office, your out-of-pocket expense will be more.

Basic Option:
Physical therapy is limited to 50 visits per calendar year. To receive benefits, go to your preferred hospital. If you choose to go to a physical therapist's office or a non-PPO provider, you are responsible for all of the charges.

9. What are my benefits for speech and occupational therapy?
Standard Option:
Speech and occupational therapy are limited to a combined total of 25 visits per person. To receive preferred benefits, go to your preferred hospital. Your out-of-pocket expense will be less. Independent speech or occupational therapists are considered nonparticipating. If you choose to go to a speech or occupational therapist's office, your out-of-pocket expense will be more.

Basic Option:
To receive benefits for speech or occupational therapy, go to your preferred hospital. If you choose to go to a speech or occupational therapist's office or a non-PPO provider, you are responsible for all of the charges.

10. What are my benefits for durable medical equipment (DME)?
Standard Option:
Benefits are based on the provider you choose. The highest benefits available are preferred. If you choose to go to a durable medical equipment company that is not preferred, your out-of-pocket expense will be more. Refer to Section 5a in the Service Benefit Plan brochure for additional information.

Basic Option:
Benefits must be provided by a preferred provider. Refer to Section 5a in the Service Benefit Plan brochure for additional information.

11. Do I have benefits to quit smoking?
After you satisfy the calendar-year deductible, the plan will pay 100 percent up to $100 for enrollment in one smoking-cessation program per member per lifetime under the High and Standard options. Services may be rendered by any covered provider or a smoking-cessation clinic.

12. Are chiropractors covered?
Standard Option:
Chiropractic services are not eligible for benefits.

Basic Option:
Benefits are available for covered services provided by network chiropractors. Covered services include the initial office visit, spinal manipulations and the initial set of X-rays. A $20 copayment applies for each visit. Benefits are limited to 20 manipulations per year.

13. What is Blue Health Connection?
Blue Health Connection is a 24-hour nurse telephone service that is available 365 days a year by calling a toll-free telephone number 1-888-258-3432 or accessing our Internet site at http://www.fepblue.org. The service features health advice or health information and counseling by registered nurses. Also available is the Audio Health Library with hundreds of topics, ranging from first aid to infectious diseases to general health issues.

Dental Benefits

1. Is a root canal or a crown covered by dental benefits?
Basic and Standard options offer basic preventive dental coverage. Eligible services are paid on a fee schedule. Major dental work, such as orthodontics, root canals or crowns, is not covered. For more information, refer to the Blue Cross and Blue Shield Service Benefit Plan brochure, Section 5h.

Standard Option:
Each of these providers should bill Arkansas Blue Cross and Blue Shield Federal Employee Program for services rendered in Arkansas. For services that meet medical-necessity guidelines, the level of benefits you receive depends on the provider's status (preferred, participating or nonparticipating provider). Refer to sections 5a, 5b and 5c in the Service Benefit Plan brochure.

Basic Option:
Each of these providers should bill Arkansas Blue Cross and Blue Shield Federal Employee Program for services rendered in Arkansas. For services that meet medical-necessity guidelines, the benefits you receive depend on whether the provider is a preferred provider. When the hospital and physician are preferred, benefits will be eligible. When the hospital or physician are not preferred, benefits will not be eligible, and you will owe all of the charges. Refer to sections 5a, 5b and 5c in the Service Benefit Plan brochure.

Vision Benefits

1. Are routine eye exams covered under the Federal Employee Service Benefit Plan?
Routine eye exams are not eligible for benefits. However, Service Benefit Plan members may obtain substantial savings from EyeMed Vision providers for eye exams and eyewear through a non-FEHB benefit. The names, addresses and telephone numbers of Vision One providers are available by calling 1-800-551-3337. Location information is available 24 hours a day. Refer to Section 5J in the Blue Cross and Blue Shield Service Benefit Plan brochure.

There are no enrollment fees and no additional paperwork or claim forms to be filed in this program. All charges for eye exams and eyewear are handled directly between you and the Vision One provider.

Pharmacy Benefits

1. What type of drug coverage do I have?
Standard Option:
If you have Standard Option coverage, you can choose to use the Mail Service or the Retail Pharmacy programs. For prescriptions obtained through Mail Service under Standard Option, there is a $10 copayment for generic drugs and a $35 copayment for brand-name drugs for up to a 90-day supply. You may reach the Mail Service Prescription Drug Program at 1-800-262-7890 or http://www.fepblue.org.

For prescriptions at a preferred retail pharmacy, the member is responsible for 25% coinsurance for up to a 90-day supply of medications at a preferred retail pharmacy. For a list of the preferred pharmacies, you may call the Retail Pharmacy Program at 1-800-624-5060 or visit http://www.fepblue.org.

Basic Option:
If you have Basic Option coverage, the Mail Service Program is not available. Basic Option uses preferred retail and Internet pharmacies. In addition, Basic Option offers a three-tier prescription drug benefit: for up to a 34-day supply of medication, members will pay $10 for generic drugs, $25 for formulary brand-name drugs and 50% for nonformulary brand-name drugs ($35 minimum). For refills, a 90-day supply is available for three copayments. For a list of the Basic Option preferred pharmacies, you may call the Retail Pharmacy Program at 1-800-624-5060 or visit http://www.fepblue.org.

2. Do some prescriptions require prior approval?
Certain prescription drugs require prior approval. Contact the Retail Pharmacy Program at 1-800-624-5060 to request prior approval or to obtain an updated list of prescription drugs that require prior approval.

3. Do I have to use the Mail-Order Program?
Standard Option:
It is your choice to use the Mail-Order Program or a local retail pharmacy.

Basic Option:
Does not offer mail-order.

4. What is the Discount Vitamin Program?
Standard Option:
Service Benefit Plan members may obtain a selection of more than 150 nonprescription vitamins, minerals and herbal products at substantial savings when they are ordered through Bio Balance, a mail order, discount program offered by Landmark/Leiner Health Products. Call 1-877-258-7283 to order products or request a catalog.

There are no enrollment fees and no additional paperwork or claim forms to be filed in this program. All charges for products offered by the Discount Vitamin Program are handled directly between you and Bio-Balance.

General

1. If I have questions about claim status or benefits, whom do I contact?
Call the customer service number that appears on your ID card.

2. If I have questions about the Explanation of Benefits (EOB), whom do I contact?
Consult your ID card for the customer service telephone number or the mailing address.

3. Why didn't I get my premium statement this month?
If you have not received your statement by the end of the month, call Customer Service at the number noted on the back of your member ID card.

4. Why do you want to know if I have other coverage?
A decision must be made as to which coverage is responsible for primary payment.

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