High Option Summary
of Benefits for the
Foreign Service
Benefit Plan

We continue to offer a comprehensive benefit package, at very competitive rates. The Plan is committed to providing the unparalleled service that our unique worldwide membership requires. We strive to demonstrate that daily through our programs and through our premiums.

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.

Benefit Enhancements for 2021

  • Added coverage for telemedicine visits for medical, mental health and substance use disorders
  • Overseas telehealth services now offered through vHealth
  • Now covers physical, occupational and speech therapy for autism and developmental delays with no visit limit
  • Increased the visit limit for chiropractic services to 50 visits per person, per calendar year
  • Increased the visit limit for acupuncture and massage therapy to 50 visits per person, per calendar year

Our New Programs include:

  • Lab Savings Program

Important Things You Should Know:

The Plan also:

  • Updated the precertification/prior approval list
  • Updated contact information for our telehealth vendor, Teladoc®
  • Clarified anesthesia coverage for the maternity care benefit
  • Clarified our coverage of breastfeeding equipment

If you have benefit questions during the Open Season enrollment period, you may contact us by e-mail at openseason@afspa.org or call us at 202-833-4910.

We look forward to bringing you these new and enhanced offerings beginning January 1, 2021.

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 2021 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
$71.75 $178.73 $177.50 $155.47 $387.25 $384.59
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
MinuteClinic® at CVS visits Nothing No benefit No benefit
Lab Savings Program Nothing for covered lab tests rendered by LabCorp or Quest Diagnostics No benefit No benefit
Massage therapy performed by a covered provider – limited to 50 visits per person, per calendar year Nothing up to the Plan maximum of $60 per visit and then all charges up to the Plan allowance; and all charges above 50 visits per person, per calendar year Nothing up to the Plan maximum of $60 per visit; and all charges above $60 per visit and/or 50 visits per person, per calendar year Nothing up to the Plan maximum of $60 per visit; and all charges above $60 per visit and/or 50 visits per person, per calendar year
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 All Charges 10% $15 for up to a 90-day supply
Level II (Preferred Brand Name) 25% ($30 minimum/$100 maximum) for up to a 30-day supply All Charges 10% $60 for up to a 90-day supply
Level III (Non-Preferred Brand Name) 35% ($60 minimum/$200 maximum) for up to a 30-day supply All Charges 10% 35% for up to a 90-day supply ($80 minimum/$500 maximum)
Level IV (Generic Specialty Drugs) 25% ($150 maximum) for up to a 30-day supply (Note: Restrictions apply on refills) All Charges 10% 25% up to maximum of $150 for up to a 90-day supply
Level V (Preferred Brand Name Specialty Drugs) 25% ($200 maximum) (Note: Restrictions apply on refills) All Charges 10% 25% up to a maximum of $200
Level VI (Non-Preferred Brand Name Specialty Drugs) 35% ($300 maximum) (Note: Restrictions apply on refills) All Charges 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
Calendar year Deductible
High Option In-Network Out-of-Network Providers outside the 50 United States – You Pay
A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Self Only $300; Self Plus one or Self and Family coverage $600 Self Only $400; Self Plus one or Self and Family coverage $800 Self Only $300; Self Plus one or Self and Family coverage $600.
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