Standard Option Summary of Benefits
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MHBP Standard Option Summary of Benefits
This is a summary of the Mail Handlers Benefit Plan Standard 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.
Medical Coverage
In the tables below we added No Deductible to show when the calendar-year deductible does not apply.
| Topic | You Pay | |
|---|---|---|
| Topic | PPO | Non-PPO |
| Calendar Year Deductible | $350 per person, limited to $700 per family | $500 per person, limited to $1,250 per family |
|
Annual Physical Exam for Adults (age 18 and over) |
$20 copayment (No deductible) | Not Covered |
| Well-Child Care | Nothing (No deductible) | All charges after the Plan has paid $75 per child per calendar year (No deductible) |
|
Preventive Screenings |
Nothing (No deductible) | 30% of the Plan's allowance and any difference between our allowance and the billed amount |
| Maternity Care | Nothing (No deductible) | 30% of the Plan's allowance and any difference between our allowance and the billed amount |
| Doctor's Office Visits | $20 copayment per office visits for adults, $10 copayment for dependent children under age 22 (No deductible) | 30% of the Plan's allowance and any difference between our allowance and the billed amount (No deductible) |
| Convenient Care Clinics | $10 copayment per visit (No deductible) | 30% of the Plan's allowance and any difference between our allowance and the billed amount (No deductible) |
| Lab, X-ray and Diagnostic Tests | 10% of the Plan's allowance | 30% 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 (No deductible) | Nothing for covered lab tests with the Lab Savings Program with Quest® Diagnostics (No deductible) |
| 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(No deductible) | 30% 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 (No deductible) |
| Hospitalization | $200 per-admission copayment, nothing for covered room & board and 15% of the Plan’s allowance for hospital ancillary services (No deductible) | $500 per-admission copayment, 30% of the Plan’s allowance and any difference between our allowance and the billed amount (No deductible) |
|
Hospitalization: Maternity |
Nothing (no deductible) | $500 per-admission copayment, 30% of the Plan’s allowance and any difference between our allowance and the billed amount (No deductible) |
| Surgery and Anesthesia | 10% of the Plan's allowance | 30% of the Plan's allowance and any difference between our allowance and the billed amount |
| Emergency Treatment | $50 copayment at an urgent care center, $150 copayment at a hospital emergency room. Hospital ER copayment waived if admitted. No deductible for accidental injury. | 30% 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 |
Nothing after your out-of-pocket expenses for covered services from PPO providers totals $4,500 per calendar year | Nothing after your out-of-pocket expenses for covered services from PPO providers and non-PPO providers combined totals $9,000 per calendar year |
Prescription Drug Coverage: Retail Pharmacy
Prescription drug coverage for retail pharmacy requires no deductible.
† Specialty drugs are used to treat chronic, complex conditions and typically require special handling and close monitoring.
| Topic | You Pay | |
|---|---|---|
| Topic | Network Pharmacy and Electronic Claims | Non-Network Pharmacies and Paper Claims |
| Generic | $10 copayment | 50% of the Plan's allowance and any difference between our allowance and the billed amount |
| Preferred brand name | $40 copayment | 50% of the Plan's allowance and any difference between our allowance and the billed amount |
| Non-Preferred brand name | $60 copayment | 50% of the Plan's allowance and any difference between our allowance and the billed amount |
| Specialty† | $100 copayment | 50% of the Plan's allowance and any difference between our allowance and the billed amount |
Prescription Drug Coverage: Mail Order Pharmacy
Prescription drug coverage for retail pharmacy requires no deductible.
† Specialty drugs are used to treat chronic, complex conditions and typically require special handling and close monitoring.
| Topic | Network Pharmacy and Electronic Claims | Non-Network Pharmacies and Paper Claims |
|---|---|---|
| Generic | $15 copayment | Not Covered |
| Preferred brand name | $65 copayment | Not Covered |
| Non-Preferred brand name | $90 copayment | Not Covered |
| Specialty† | $300 copayment | Not Covered |
The Mail Handlers Benefit Plan 2010 Standard Option Rates
These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to your FEHBP Guide or contact the agency that maintains your health benefits enrollment.
| Topic | Federal Employees Biweekly | Postal Employees Biweekly | Annuitants Monthly |
|---|---|---|---|
| Self Only (454) | $76.62 | $53.34 | $166.01 |
| Self and Family (455) | $182.90 | $130.67 | $396.29 |
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.
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