2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(i). Services, Drugs, and Supplies Provided Overseas
Section 5. Benefits
Section 5(i). Services, Drugs, and Supplies Provided Overseas
Section 5(i). Services, Drugs, and Supplies Provided Overseas
If you travel or live outside the United States, Puerto Rico, and the U.S. Virgin Islands, you are still entitled to the benefits described in this brochure. Unless otherwise noted in this Section, the same definitions, limitations, and exclusions also apply. Costs associated with repatriation from an international location back to the United States are not covered. See Section 10 for a definition of repatriation. See below and pages 131-132 for the claims information we need to process overseas claims. We may request that you provide complete medical records from your provider to support your claim. If you plan to receive healthcare services in a country sanctioned by the Office of Foreign Assets Control (OFAC) of the U.S. Department of the Treasury, your claim must include documentation of a government exemption under OFAC authorizing care in that country.
Please note that the requirements to obtain precertification for inpatient care and prior approval for those services listed in Section 3 do not apply when you receive care overseas, with the exception of admissions for gender affirming surgery (see pages 22 and 66-67 for information) and admissions to residential treatment centers and skilled nursing facilities. Prior approval is required for all non-emergent air ambulance transport services for overseas members (refer to page 92 for more information). Protections offered under the NSA (see page 32) do not apply to overseas claims.
Please note that the requirements to obtain precertification for inpatient care and prior approval for those services listed in Section 3 do not apply when you receive care overseas, with the exception of admissions for gender affirming surgery (see pages 22 and 66-67 for information) and admissions to residential treatment centers and skilled nursing facilities. Prior approval is required for all non-emergent air ambulance transport services for overseas members (refer to page 92 for more information). Protections offered under the NSA (see page 32) do not apply to overseas claims.
Overseas Assistance Center
We have a network of participating hospitals overseas that will file your claims for inpatient facility care for you – without an advance payment for the covered services you receive. We also have a network of professional providers who have agreed to accept a negotiated amount as payment in full for their services. The Overseas Assistance Center can help you locate a hospital or physician in our network near where you are staying. You may also view a list of our network providers on our website, www.fepblue.org. You will have to file a claim to us for reimbursement for professional services unless you or your provider contacts the Overseas Assistance Center in advance to arrange direct billing and payment to the provider.
If you are overseas and need assistance locating providers (whether in or out of our network), contact the Overseas Assistance Center (provided by GMMI), by calling 804-673-1678. Members in the United States, Puerto Rico, or the U.S. Virgin Islands should call 800-699-4337 or email the Overseas Assistance Center at fepoverseas@gmmi.com. GMMI, also offers emergency evacuation services to the nearest facility equipped to adequately treat your condition, translation services, and conversion of foreign medical bills to U.S. currency. You may contact one of their multilingual operators 24 hours a day, 365 days a year.
Hospital and professional provider benefits
For professional care you receive overseas, we provide benefits at Preferred benefit levels using either our Overseas Fee Schedule, a customary percentage of the billed charge, or a provider-negotiated discount as our Plan allowance. The Basic Option requirement to use Preferred providers in order to receive benefits does not apply when you receive overseas care. Standard Option members have no deductible for overseas services.
Under both Standard and Basic Options, when the Plan allowance is based on the Overseas Fee Schedule, you pay any difference between our payment and the amount billed, in addition to any applicable coinsurance and/or copayment amounts. When the Plan allowance is a provider-negotiated discount, you are only responsible for your coinsurance and/or copayment amounts. You must also pay any charges for noncovered services.
For inpatient facility care you receive overseas, we provide benefits at the Preferred level under both Standard and Basic Options. For Basic Option, there is no member cost-share for admissions to a DoD facility, or when the Overseas Assistance Center (provided by GMMI) has arranged direct billing or acceptance of a guarantee of benefits with the facility. For all other inpatient facility care, Basic Option members are responsible for the per admission copayment. Standard Option members have no cost-share for inpatient facility care.
For outpatient facility care you receive overseas, we provide benefits at the Preferred level under both Standard and Basic Options after you pay the applicable copayment or coinsurance. Standard Option members have no deductible for overseas services.
For dental care you receive overseas, we provide benefits as described in Section 5(g). Under Standard Option, you must pay any difference between the Schedule of Dental Allowances and the dentist’s charge, in addition to any charges for noncovered services. Under Basic Option, you must pay the $30 copayment plus any difference between our payment and the dentist’s charge, as well as any charges for noncovered services.
For transport services you receive overseas, we provide benefits for transport services to the nearest hospital equipped to adequately treat your condition when the transport services are medically necessary. We provide benefits as described in Section 5(c) and Section 5(d). Benefits are not available for costs associated with transportation to other than the closest hospital equipped to treat your condition. Under Standard and Basic Options, members pay the applicable copayment.
Pharmacy benefits
For prescription drugs purchased at overseas pharmacies, we provide benefits at Preferred benefit levels, using the billed charge as our Plan allowance. Under both Standard and Basic Options, members pay the applicable coinsurance. Standard Option members are not required to meet the calendar year deductible when they purchase drugs at pharmacies located overseas. See page 119 in Section 5(f) for more information.
Overseas claims payment
Most overseas providers are under no obligation to file claims on behalf of our members. Follow the procedures listed below to file claims for covered services and drugs you receive outside the United States, Puerto Rico, and the U.S. Virgin Islands. You may need to pay for the services at the time you receive them and then send a claim to us for reimbursement. We will provide translation and currency conversion services for your overseas claims.
Filing overseas claims
To file a claim for covered hospital and professional provider services received outside the United States, Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Overseas Medical Claim Form, by mail, fax, or internet, along with itemized bills from the provider. In completing the claim form, indicate whether you want to be paid in U.S. dollars or in the currency reflected on the itemized bills, and if you want to receive payment by check or bank wire. Use the following information to mail, fax, or submit your claim electronically:
If you have questions about your medical claims, call us at 888-999-9862, using the AT&T Direct Access Code of the country from which you are calling, or email us through our website (www.fepblue.org) via the MyBlue portal. You may also write to us at: Mailroom Administrator, FEP Overseas Claims, P.O. Box 14112, Lexington, KY 40512-4112. You may obtain Overseas Medical Claim Forms from our website, by email at fepoverseas@gmmi.com, or from your Local Plan.
Filing a claim for pharmacy benefits
Drugs purchased overseas must be the equivalent to drugs that by Federal law of the United States require a prescription. To file a claim for covered drugs and supplies you purchase from pharmacies outside the United States, Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Retail Prescription Drug Overseas Claim Form, along with itemized pharmacy receipts or bills. Timely filing for overseas pharmacy claims is limited to one year from the prescription fill date. Use the following information to mail, fax, or submit your claim electronically:
Send any written inquiries concerning drugs you purchase overseas to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057. You may obtain FEP Retail Prescription Drug Overseas Claim forms for your drug purchases by visiting our website, www.fepblue.org, by writing to the address above, or by calling us at 888-999-9862, using the AT&T Direct Access Code of the country from which you are calling.
While overseas, you may be able to order your prescription drugs through the Mail Service Prescription Drug Program or our Specialty Drug Pharmacy Program as long as all of the following conditions are met:
See Section 5(f) for more information about Preferred retail pharmacies with online ordering options, the Mail Service Prescription Drug Program, and the Specialty Drug Pharmacy Program.
The Mail Service Prescription Drug Program is available to Standard Option members and to Basic Option members with primary Medicare Part B coverage.
Note: In most cases, temperature-sensitive drugs cannot be sent to APO/FPO addresses due to the special handling they require.
Note: We are unable to ship drugs, through either our Mail Service Prescription Drug Program or our Specialty Drug Pharmacy Program, to overseas countries that have laws restricting the importation of prescription drugs from any other country. This is the case even when a valid APO or FPO address is available. If you are living in such a country, you may obtain your prescription drugs from a local overseas pharmacy and submit a claim to us for reimbursement by faxing it to 001-480-614-7674 or filing it via our website at www.fepblue.org/myblue.
We have a network of participating hospitals overseas that will file your claims for inpatient facility care for you – without an advance payment for the covered services you receive. We also have a network of professional providers who have agreed to accept a negotiated amount as payment in full for their services. The Overseas Assistance Center can help you locate a hospital or physician in our network near where you are staying. You may also view a list of our network providers on our website, www.fepblue.org. You will have to file a claim to us for reimbursement for professional services unless you or your provider contacts the Overseas Assistance Center in advance to arrange direct billing and payment to the provider.
If you are overseas and need assistance locating providers (whether in or out of our network), contact the Overseas Assistance Center (provided by GMMI), by calling 804-673-1678. Members in the United States, Puerto Rico, or the U.S. Virgin Islands should call 800-699-4337 or email the Overseas Assistance Center at fepoverseas@gmmi.com. GMMI, also offers emergency evacuation services to the nearest facility equipped to adequately treat your condition, translation services, and conversion of foreign medical bills to U.S. currency. You may contact one of their multilingual operators 24 hours a day, 365 days a year.
Hospital and professional provider benefits
For professional care you receive overseas, we provide benefits at Preferred benefit levels using either our Overseas Fee Schedule, a customary percentage of the billed charge, or a provider-negotiated discount as our Plan allowance. The Basic Option requirement to use Preferred providers in order to receive benefits does not apply when you receive overseas care. Standard Option members have no deductible for overseas services.
Under both Standard and Basic Options, when the Plan allowance is based on the Overseas Fee Schedule, you pay any difference between our payment and the amount billed, in addition to any applicable coinsurance and/or copayment amounts. When the Plan allowance is a provider-negotiated discount, you are only responsible for your coinsurance and/or copayment amounts. You must also pay any charges for noncovered services.
For inpatient facility care you receive overseas, we provide benefits at the Preferred level under both Standard and Basic Options. For Basic Option, there is no member cost-share for admissions to a DoD facility, or when the Overseas Assistance Center (provided by GMMI) has arranged direct billing or acceptance of a guarantee of benefits with the facility. For all other inpatient facility care, Basic Option members are responsible for the per admission copayment. Standard Option members have no cost-share for inpatient facility care.
For outpatient facility care you receive overseas, we provide benefits at the Preferred level under both Standard and Basic Options after you pay the applicable copayment or coinsurance. Standard Option members have no deductible for overseas services.
For dental care you receive overseas, we provide benefits as described in Section 5(g). Under Standard Option, you must pay any difference between the Schedule of Dental Allowances and the dentist’s charge, in addition to any charges for noncovered services. Under Basic Option, you must pay the $30 copayment plus any difference between our payment and the dentist’s charge, as well as any charges for noncovered services.
For transport services you receive overseas, we provide benefits for transport services to the nearest hospital equipped to adequately treat your condition when the transport services are medically necessary. We provide benefits as described in Section 5(c) and Section 5(d). Benefits are not available for costs associated with transportation to other than the closest hospital equipped to treat your condition. Under Standard and Basic Options, members pay the applicable copayment.
Pharmacy benefits
For prescription drugs purchased at overseas pharmacies, we provide benefits at Preferred benefit levels, using the billed charge as our Plan allowance. Under both Standard and Basic Options, members pay the applicable coinsurance. Standard Option members are not required to meet the calendar year deductible when they purchase drugs at pharmacies located overseas. See page 119 in Section 5(f) for more information.
Overseas claims payment
Most overseas providers are under no obligation to file claims on behalf of our members. Follow the procedures listed below to file claims for covered services and drugs you receive outside the United States, Puerto Rico, and the U.S. Virgin Islands. You may need to pay for the services at the time you receive them and then send a claim to us for reimbursement. We will provide translation and currency conversion services for your overseas claims.
Filing overseas claims
To file a claim for covered hospital and professional provider services received outside the United States, Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Overseas Medical Claim Form, by mail, fax, or internet, along with itemized bills from the provider. In completing the claim form, indicate whether you want to be paid in U.S. dollars or in the currency reflected on the itemized bills, and if you want to receive payment by check or bank wire. Use the following information to mail, fax, or submit your claim electronically:
- Mail: Federal Employee Program, Overseas Claims, P.O. Box 260070, Pembroke Pines, FL 33026.
- Fax: 001-954-308-3957. Be sure to first dial the AT&T Direct Access Code of the country from which you are faxing the claim.
- Internet: Go to the MyBlue portal on www.fepblue.org. If you are already a registered MyBlue portal user, click on the “Health Tools” menu and, in the “Get Care” section, select “Submit Overseas Claim” and follow the instructions for submitting a medical claim. If you are not yet a registered user, go to MyBlue, click on the “Sign Up” link, and register to use the online filing process.
If you have questions about your medical claims, call us at 888-999-9862, using the AT&T Direct Access Code of the country from which you are calling, or email us through our website (www.fepblue.org) via the MyBlue portal. You may also write to us at: Mailroom Administrator, FEP Overseas Claims, P.O. Box 14112, Lexington, KY 40512-4112. You may obtain Overseas Medical Claim Forms from our website, by email at fepoverseas@gmmi.com, or from your Local Plan.
Filing a claim for pharmacy benefits
Drugs purchased overseas must be the equivalent to drugs that by Federal law of the United States require a prescription. To file a claim for covered drugs and supplies you purchase from pharmacies outside the United States, Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Retail Prescription Drug Overseas Claim Form, along with itemized pharmacy receipts or bills. Timely filing for overseas pharmacy claims is limited to one year from the prescription fill date. Use the following information to mail, fax, or submit your claim electronically:
- Mail: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.
- Fax: 001-480-614-7674. Be sure to first dial the AT&T Direct Access Code of the country from which you are faxing the claim.
- Internet: Go to the MyBlue portal on www.fepblue.org. If you are already a registered MyBlue portal user, click on the “Health Tools” menu and, in the “Get Care” section, select “Submit Overseas Claim” and follow the instructions for submitting a pharmacy claim. If you are not yet a registered user, go to MyBlue, click on the “Sign Up” link, and register to use the online filing process.
Send any written inquiries concerning drugs you purchase overseas to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057. You may obtain FEP Retail Prescription Drug Overseas Claim forms for your drug purchases by visiting our website, www.fepblue.org, by writing to the address above, or by calling us at 888-999-9862, using the AT&T Direct Access Code of the country from which you are calling.
While overseas, you may be able to order your prescription drugs through the Mail Service Prescription Drug Program or our Specialty Drug Pharmacy Program as long as all of the following conditions are met:
- Your address includes a U.S. ZIP code (such as with APO and FPO addresses and in U.S. territories),
- The prescribing physician is licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, and has a National Provider Identifier (NPI), and
- Delivery of the prescription is permitted by law and is in accordance with the manufacturer’s guidelines.
See Section 5(f) for more information about Preferred retail pharmacies with online ordering options, the Mail Service Prescription Drug Program, and the Specialty Drug Pharmacy Program.
The Mail Service Prescription Drug Program is available to Standard Option members and to Basic Option members with primary Medicare Part B coverage.
Note: In most cases, temperature-sensitive drugs cannot be sent to APO/FPO addresses due to the special handling they require.
Note: We are unable to ship drugs, through either our Mail Service Prescription Drug Program or our Specialty Drug Pharmacy Program, to overseas countries that have laws restricting the importation of prescription drugs from any other country. This is the case even when a valid APO or FPO address is available. If you are living in such a country, you may obtain your prescription drugs from a local overseas pharmacy and submit a claim to us for reimbursement by faxing it to 001-480-614-7674 or filing it via our website at www.fepblue.org/myblue.