2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Table of Contents
Page 2
Table of Contents
Page 2
• If your hospital stay needs to be extended - 27
• If your treatment needs to be extended - 27
If you disagree with our pre-service claim decision - 27
• To reconsider a non-urgent care claim - 27
• To reconsider an urgent care claim - 28
• To file an appeal with OPM - 28
• If your treatment needs to be extended - 27
If you disagree with our pre-service claim decision - 27
• To reconsider a non-urgent care claim - 27
• To reconsider an urgent care claim - 28
• To file an appeal with OPM - 28
Section 4. Your Costs for Covered Services - 29
Cost-share/Cost-sharing - 29
Copayment - 29
Deductible - 29
Coinsurance - 29
If your provider routinely waives your cost - 29
Waivers - 30
Differences between our allowance and the bill - 30
Important Notice About Surprise Billing – Know Your Rights - 30
Your costs for other care - 31
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 31
Carryover - 32
If we overpay you - 32
When Government facilities bill us - 32
Section 5. FEP Blue Focus Benefits - 33Deductible - 29
Coinsurance - 29
If your provider routinely waives your cost - 29
Waivers - 30
Differences between our allowance and the bill - 30
Important Notice About Surprise Billing – Know Your Rights - 30
Your costs for other care - 31
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 31
Carryover - 32
If we overpay you - 32
When Government facilities bill us - 32
Non-PSHB Benefits Available to Plan Members - 110
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 111
Section 7. Filing a Claim for Covered Services - 113
Section 8. The Disputed Claims Process - 116
Section 8(a). Medicare PDP EGWP Disputed Claims Process - 119
Section 9. Coordinating Benefits With Medicare and Other Coverage - 120
• Workers’ Compensation - 121
• Medicaid - 121
When other Government agencies are responsible for your care - 121
• Medicaid - 121
When other Government agencies are responsible for your care - 121
When others are responsible for injuries - 121
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 122
Clinical trials - 123
When you have Medicare - 123
• The Original Medicare Plan (Part A or Part B) - 123
• Tell us about your Medicare coverage - 124
• Private contract with your physician - 124
• Medicare Advantage (Part C) - 124
• Medicare prescription drug coverage (Part D) - 125
• Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) - 125
• Medicare prescription drug coverage (Part B) - 126
When you are age 65 or over and do not have Medicare -128
Physicians Who Opt-Out of Medicare - 129
When you have the Original Medicare Plan (Part A, Part B, or both) - 129
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 122
Clinical trials - 123
When you have Medicare - 123
• The Original Medicare Plan (Part A or Part B) - 123
• Tell us about your Medicare coverage - 124
• Private contract with your physician - 124
• Medicare Advantage (Part C) - 124
• Medicare prescription drug coverage (Part D) - 125
• Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) - 125
• Medicare prescription drug coverage (Part B) - 126
When you are age 65 or over and do not have Medicare -128
Physicians Who Opt-Out of Medicare - 129
When you have the Original Medicare Plan (Part A, Part B, or both) - 129
Section 10. Definitions of Terms We Use in This Brochure - 131
Index - 140Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2025 - 142