Consumer Option Summary Of Benefits

MHBP Consumer Option Summary of Benefits

This is a summary of the Mail Handlers Benefit Plan Consumer Option. Before making a final decision, please read the official Plan brochure (RI 71-007). All benefits are subject to the definitions, limitations and exclusions set forth in the official Plan brochure.

Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA)

Health Savings Account / Health Reimbursement Arrangement

Topic	HSA Annual Contribution	HRA Annual Contribution
MHBP	Up to $845 (self only) or up to $1,690 (self & family)	Up to $845 (self only) or up to $1,690 (self & family)
Member (optional)	Up to $2,205 (self only) or up to $4,460 (self & family)	Not applicable

Calendar-Year Deductible

The calendar-year deductible applies to most benefits. In the tables below we added No Deductible to show when the calendar-year deductible does not apply.

Calendar-Year Deductible

Topic	Self Only	Self and Family
Calendar-Year Deductible	$2,000	$4,000

PPO Preventive Care

PPO Preventive Care

Topic	You Pay
Topic	PPO	Non-PPO
Routine Physical Exam & Immunizations	Nothing (no deductible)	Not covered
Routine Preventive Screenings	Nothing (no deductible)	Not covered

Traditional Medical Coverage

Deductible must be met before benefits begin.

Traditional Medical Coverage

Topic	You Pay
Topic	PPO	Non-PPO
Doctor's Office Visits	$15 copayment per office visits, including associated testing.	40% of the plan's allowance and any difference between our allowance and the billed amount.
Convenient Care Clinics	$10 copayment per visit	40% of the Plan's allowance and any difference between our allowance and the billed amount
Lab, X-Ray, and Diagnostic Tests	$15 copayment per office visit, including associated testing	40% of the plan's allowance and any difference between our allowance and the billed amount
Lab Savings Program	Nothing for covered lab tests with the lab Savings program with Quest® Diagnostics	Nothing for covered lab tests with the lab Savings program with Quest® Diagnostics
Chiropractic Care	$15 copayment per office visit, and all charges after the plan has paid the $2,500 combined alternative, chiropractic and rehabilitative therapies maximum	40% of the plan's allowance and any difference between our allowance and the billed amount, and all charges after the plan has paid the $2.500 combined alternative, chiropractic and rehabilitative therapies maximum
Hospitalization	Nothing for covered room & board and $75 per day up to $750 for hospital ancillary services	40% of the plan's allowance and any difference between our allowance and the billed amount
Outpatient Surgical Facility	$150 copayment per occurrence	40% of the plan's allowance and any difference between our allowance and the billed amount
Surgery and Anesthesia	Nothing in hospital; $15 copayment in doctor's office	40% of the plan's allowance and any difference between our allowance and the billed amount
Emergency Treatment	$50 copayment per occurrence	40% of the plan's allowance and any difference between our allowance and the billed amount
Overseas Medical Expenses	PPO-level benefits for covered care received outside of the United States	PPO-level benefits for covered care received outside of the United States
Catastrophic Protection (Some costs do not count toward this protection)	Nothing after your out-of-pocket expenses for covered services from PPO providers totals $5,000 per calendar year for self only enrollment ($10,000 for self and family enrollment)	Nothing after your out-of-pocket expenses for covered services from PPO providers and non-PPO providers combined totals $7,500 per calendar year for self only enrollment ($15,000 for self and family enrollment)

Prescription Drug Coverage: Retail  Pharmacy

Retail Pharmacy—Up To A 30-Day Supply

Topic	You Pay
Topic	Network Pharmacy and Electronic Claims	Non-Network Pharmacies and Paper Claims
Generic	$10 copayment	Not covered
Preferred brand name	$25 copayment	Not covered
Non-Preferred brand name	$40 copayment	Not covered

Prescription Drug Coverage: Mail Order  Pharmacy

Mail Order Pharmacy—Up To A 90-Day Supply

Topic	You Pay
Topic	Network Pharmacy and Electronic Claims	Non-Network Pharmacies and Paper Claims
Generic	$20 copayment	Not covered
Preferred brand name	$50 copayment	Not covered
Non-Preferred brand name	$80 copayment	Not covered

Special Member Benefits*

Vision care discounts and savings from EyeMed Vision Care providers, laser vision correction savings from the U.S. Laser Network and QualSight, a hearing aid discount program from HearPO, healthy living and fitness benefits from GlobalFit and savings on everyday health-related items through the CVS Caremark ExtraCare Health Card program.

* These benefits are neither offered nor guaranteed under contract with the FEHBP, but are made available to all MHBP enrollees and their covered family members. You cannot file a FEHBP disputed claim about them. The fees you pay for these services do not count toward the FEHBP deductibles or out-of-pocket maximums.