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Summary of Benefits and Coverage: What this Plan Covers ...
Benefits may vary if you have other coverage, such as Medicare. For general ... minimum (30-day supply) Not covered $210 minimum for a 31 to 90-day supply for additional copayments Tier 4 (Preferred Specialty ... incident prescribed for certain medical conditions.
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A Fee-For-Service Plan (FEP Blue Focus) with a Preferred ...
www.fepblue.orgFEP® Blue Focus www.fepblue.org 2022 A Fee-For-Service Plan (FEP Blue Focus) with a Preferred Provider Organization IMPORTANT • Rates: Back Cover • Changes for 2022: Page 15 • Summary of Benefits: Page 139 This Plan’s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides.
Blue Cross and Blue Shield Service Benefit Plan
www.fepblue.orgIntroduction This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Standard and FEP Blue Basic Options under contract (CS 1039) between the Blue Cross and Blue Shield Association and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law.
WE CAN BE THERE - Blue Cross and Blue Shield's Federal ...
www.fepblue.orgMedicare and Blue. The Blue Cross and Blue Shield Service Benefit Plan is the number one choice of federal. retirees in the Federal Employees Health Benefits Program. For 60 years, we’ve been covering federal employees and retirees. When you retire, your Service Benefit Plan coverage doesn’t change. •
Blue Cross Blue Shield FEP DentalSM
www.fepblue.org• Summary of Benefits: Page 47 Who may enroll in this Plan: All Federal employees, annuitants, ... Act of 2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplemental dental and vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members ...
Blue Cross and Blue Shield Service Benefit Plan
www.fepblue.orgLocal Plan at the phone number appearing on the back of your ID card. The Blue Cross and Blue Shield Association is the Carrier of the Plan. The address for the Blue Cross and Blue Shield Service Benefit Plan administrative office is: Blue Cross and Blue Shield Service Benefit Plan. 1310 G Street NW, Suite 900 Washington, DC 20005
MEDICARE REIMBURSEMENT ACCOUNT (MRA) CLAIM …
www.fepblue.orgSubmit your completed claim via toll-free fax: (877) 353-9236 OR mail: Claims Administrator, PO Box 14053 Lexington, KY 40512 I certify that the information on this form is accurate and complete. I am requesting reimbursement for Medicare Part B premium expenses I incurred
FEDERAL EMPLOYEE PROGRAM DESIGNATION OF …
www.fepblue.orgFOR THE DISPUTED CLAIMS PROCESS Name of the Blue Cross and Blue Shield Service Benefit Plan member: _____ Name of person granting authorization and relationship to Service Benefit Plan member (if other than the member) (e.g., parent, personal representative):
MEDICARE REIMBURSEMENT ACCOUNT (MRA) - FEP Blue
www.fepblue.orgHealthEquity is an independent company that administers the Medicare Reimbursement Account on behalf of the BCBS Service Benefit Plan. The Blue Cross ® and Blue Shield words and symbols, Federal Employee Program and FEP® are all trademarks owned by Blue Cross Blue Shield Association.
RETAIL PRESCRIPTION DRUG CLAIM FORM Service Benefit …
www.fepblue.orgRETAIL PRESCRIPTION DRUG CLAIM FORM Service Benefit Plan for Federal Employees and Retirees PLEASE TYPE OR PRINT IN ALL CAPITAL LETTERS. SEE REVERSE FOR INSTRUCTIONS. ENROLLEE INFORMATION ENROLLEE'S First Last Name Name Initial Street Address Apartment Number, Suite OR P.O. Box Number City State Zip Code Service Benefit …
2022 BENEFIT SUMMARY BOOK Blue Cross and Blue Shield ...
www.fepblue.orgby AllianceRx Walgreens Prime. • We’re expanding the list of non-covered drugs under all three products. • Walgreens and Duane Reade Pharmacies will no longer be in-network retail pharmacies for FEP Blue Focus members. You must use in-network pharmacies to use your pharmacy benefit.
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NOTICE TO VETERAN OF EVIDENCE NECESSARY TO …
www.vba.va.gov€ € € If claiming benefits for a seriously disabled child,€all, if any, relevant, private medical treatment € records for the child's pertinent disabilities. € FDC Criteria (Claim(s) for Veterans Pension Benefits 1. Submit your claim on a signed and completed VA Form 21P-527EZ,€ Application for Veterans Pensio. n (attached). 2.