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Cover Page and Inside Cover
Table of Contents
Introduction/Plain Language/Advisory
PSHB Facts
Section 1
Section 2
Section 3
Section 4
Section 5
5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
5(d). Emergency Services/Accidents
5(e). Mental Health and Substance Use Disorder Benefits
5(f). Prescription Drug Benefits
5(f)(a). FEP Medicare Prescription Drug Plan
5(g). Dental Benefits
5(h). Wellness and Other Special Features
5(i). Services, Drugs, and Supplies Provided Overseas
Non-PSHB Benefits Available to Plan Members
Section 6
Section 7
Section 8
Section 8(a)
Section 9
Section 10
Index
Summary of Benefits – FEP Blue Focus
2025 Rate Information
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(g). Dental Benefits

 

Section 5(g). Dental Benefits

 

Important things you should keep in mind about these benefits:
 
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
     
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your PSHB Plan will be the primary payor for any covered services and your FEDVIP Plan will be secondary to your PSHB Plan. See Section 9, Coordinating Benefits with Medicare and Other Coverage, for additional information.
     
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
     
  • The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family enrollment). We state whether or not the calendar year deductible applies for each benefit listed in this section.
     
  • You must use Preferred providers in order to receive accidental dental injury benefits for treatment after 72 hours of the accident. Covered services provided more than 72 hours after an accident are subject to the deductible and coinsurance.
 

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