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Father & Child

High Option Summary of Benefits

High Option Summary
of Benefits for the
Foreign Service
Benefit Plan

Please do not rely on this chart alone. Below is a summary of covered expenses. For more detail about definitions, limitations, and exclusions please refer to the Official Plan Brochure.

Review the Summary of Benefits and Coverage chart.

In the summary below, an asterisk (*) marks the item as subject to the $300 calendar year deductible. After the yearly deductible is met the plan will pay expenses. Generally, you will pay any difference between our allowance and the billed amount if you use an out-of-network provider.

The Foreign Service Benefit Plan is a fee-for-service health insurance plan that is underwritten by the American Foreign Service Protective Association.

 

These rates do not apply to all enrollees. If you are in a special enrollment category, please contact the agency that maintains your health benefits enrollment.

Foreign Service Benefit Plan 2019 Premiums
Bi-Weekly Premium Monthly Premium
Self Only
Code 401
Self Plus One
Code 403
Self and Family
Code 402
Self Only
Code 401
Self Plus One
Code 403
Self and Family
Code 402
$67.04 $164.59 $165.86 $145.26 $356.61 $359.37

 

Medical Services Provided by Physicians
High Option Benefit In-Network - You Pay Out-of-Network - You Pay Providers outside the 50 United States - You Pay
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*
Surgical Procedures 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
High Option Benefit In-Network - You Pay Out-of-Network - You Pay Providers outside the 50 United States - You Pay
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
High Option Benefit In-Network - You Pay Out-of-Network - You Pay Providers outside the 50 United States - You Pay
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 and substance abuse
High Option Benefit In-Network - You Pay Out-of-Network - You Pay Providers outside the 50 United States - You Pay
Mental health and substance abuse Your cost-sharing responsibilities are no greater than for other illnesses or conditions. Your cost-sharing responsibilities are no greater than for other illnesses or conditions. Your cost-sharing responsibilities are no greater than for other illnesses or conditions.
Prescription Drugs

The Foreign Service Benefit Plan's (FSBP) Pharmacy Benefit Manager is Express Scripts (ESI). ESI manages the Plan’s prescription drug benefit for retail and home delivery services and has provided quality prescription drug benefit services to our Plan members for almost 30 years.

Below is a summary of the Plan's coverage:

FSBP works with ESI to give you helpful online pharmacy services through FSBP‘s co-branded website. Login or register and you can:

  • Refill and renew prescriptions easily
  • Check order status
  • Review pharmacy benefits
  • Compare costs and coverage
  • Learn about low-cost generic drugs
High Option Benefit Network Retail pharmacy-pharmacies inside the 50 United States. You cannot claim reimbursement from the Plan - You Pay
Note: After two courtesy fills of non-specialty maintenance medication, you must use a Smart90® pharmacy or home delivery.
Non-Network Retail pharmacy - pharmacies inside the 50 United States. You cannot claim reimbursement from the Plan - You Pay Retail Pharmacy - retail pharmacies outside the 50 United States (claim reimbursement from the Plan) no deductible - You Pay Smart90 Retail Network pharmacy or Home Delivery - Express Scripts; or Accredo by Mail - You Pay
Level 1 (Generic) $10 copay for up to a 30-day supply 100% 10% $15 for up to a 90-day supply
Level II (Preferred Brand Name) 25% ($30 minimum) for up to a 30-day supply 100% 10% $60 for up to a 90-day supply
Level III (Non-Preferred Brand Name) 35% ($60 minimum) for up to a 30-day supply 100% 10% 35% for up to a 90-day supply ($80 minimum/$500 maximum)
Level IV (Generic Specialty Drugs) 25% for up to a 30-day supply (Note: Restrictions apply on refills) 100% 10% 25% up to maximum of $150 for up to a 90-day supply
Level V (Preferred Brand Name Specialty Drugs) 25% (Note: Restrictions apply on refills) 100% 10% 25% up to a maximum of $200
Level VI (Non-Preferred Brand Name Specialty Drugs) 35% (Note: Restrictions apply on refills) 100% 10% 35% up to a maximum of $300
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 per course of treatment and 100% after our maximum payment of $1,000

 

Protection Against Catastrophic Costs
High Option Benefit In-Network - You Pay Out-of-Network - You Pay Providers outside the 50 United States - You Pay
Protection against catastrophic costs (out-of-pocket maximum)

Note: Benefit maximums still apply and some costs do not count toward this protection.

Nothing after $5,000/Self Only or $7,000/Self and Family enrollment per year Nothing after $7,000/Self Only or $9,000/Self and Family enrollment per year Nothing after $5,000/Self Only or $7,000/Self and Family enrollment per year

 

 
Learn more

Learn how to enroll in the Foreign Service Benefit Plan.

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