2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2025
Page 143
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2025
Page 143
Emergency benefits: Accidental injury
You pay:
Preferred: Nothing for outpatient hospital and physician services within 72 hours (regular benefits apply thereafter)
Non-preferred:
Page(s): 77
Emergency benefits: Medical emergency
You pay:
Professional, outpatient hospital:
Preferred urgent care: $25 copayment; PPO and Non-PPO emergency room care: 30%* of our allowance (deductible applies); Regular benefits for physician and hospital care* provided in other than the emergency room/PPO urgent care center
Maternity:
Ambulance transport services: 30%* of our allowance (deductible applies)
Non-preferred (Participating/Non-participating) urgent care center: You pay all charges
Page(s): 78
Mental health visits
You pay:
Preferred provider: $10 for the first 10 visits per calendar year (combined medical and mental health and substance use disorder)
After the 10th visit: 30%* of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 81
Mental health and substance use disorder treatment (inpatient and outpatient)
You pay:
Preferred provider: 30%* of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 81-83
Prescription drugs: Retail Pharmacy Program
You pay:
Preferred retail pharmacy Tier 1 (generic): $5 copayment up to a 30-day supply
Preferred retail pharmacy Tier 2 (brand name): 40% coinsurance of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
Non-preferred pharmacy: You pay all charges
Page(s): 88
Prescription drugs: Specialty Drug Pharmacy Program
You pay:
Preferred specialty pharmacy
Tier 2: 40% coinsurance of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
Page(s): 89
You pay:
Preferred: Nothing for outpatient hospital and physician services within 72 hours (regular benefits apply thereafter)
Non-preferred:
- Participating: Nothing for outpatient hospital and physician services within 72 hours (regular benefits thereafter)
- Non-participating: Any difference between the Plan allowance and billed amount for outpatient hospital and physician services within 72 hours; regular benefits thereafter
Page(s): 77
Emergency benefits: Medical emergency
You pay:
Professional, outpatient hospital:
Preferred urgent care: $25 copayment; PPO and Non-PPO emergency room care: 30%* of our allowance (deductible applies); Regular benefits for physician and hospital care* provided in other than the emergency room/PPO urgent care center
Maternity:
Ambulance transport services: 30%* of our allowance (deductible applies)
Non-preferred (Participating/Non-participating) urgent care center: You pay all charges
Page(s): 78
Mental health visits
You pay:
Preferred provider: $10 for the first 10 visits per calendar year (combined medical and mental health and substance use disorder)
After the 10th visit: 30%* of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 81
Mental health and substance use disorder treatment (inpatient and outpatient)
You pay:
Preferred provider: 30%* of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 81-83
Prescription drugs: Retail Pharmacy Program
You pay:
Preferred retail pharmacy Tier 1 (generic): $5 copayment up to a 30-day supply
Preferred retail pharmacy Tier 2 (brand name): 40% coinsurance of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
Non-preferred pharmacy: You pay all charges
Page(s): 88
Prescription drugs: Specialty Drug Pharmacy Program
You pay:
Preferred specialty pharmacy
Tier 2: 40% coinsurance of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
Page(s): 89