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 142
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2025
Page 142
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2025
Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this PSHB brochure.
You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.fepblue.org/brochure.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
Below, an asterisk (*) means the item is subject to the $500 per person ($1,000 per Self Plus One or Self and Family enrollment) calendar year deductible. If you use a Non-PPO physician, benefits are not provided.
You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.fepblue.org/brochure.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
Below, an asterisk (*) means the item is subject to the $500 per person ($1,000 per Self Plus One or Self and Family enrollment) calendar year deductible. If you use a Non-PPO physician, benefits are not provided.
Medical services provided by physicians, specialists and other healthcare professionals: Preventive, adult
You pay:
Preferred provider: Nothing
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 39-41
Medical services provided by physicians, specialists and other healthcare professionals: Preventive, child
You pay:
Preferred provider: Nothing
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 41-43
Medical services provided by physicians, specialists and other healthcare professionals: Professional 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): 37
Medical services provided by physicians, specialists and other healthcare professionals: Diagnostic and treatment services provided in the office
You pay:
Preferred provider: 30%* of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 38
Medical services provided by physicians, specialists and other healthcare professionals: Telehealth services
You pay:
Preferred Telehealth Provider: Nothing
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 37, 81
Services provided by a hospital: Inpatient
You pay:
Preferred: 30%* of the Plan allowance (deductible applies)
Non-preferred (Member/Non-member): You pay all charges
Page(s): 65-66
Services provided by a hospital: Outpatient
You pay:
Preferred: 30%* of the Plan allowance (deductible applies)
Non-preferred (Member/Non-member): You pay all charges
Page(s): 68-71
You pay:
Preferred provider: Nothing
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 39-41
Medical services provided by physicians, specialists and other healthcare professionals: Preventive, child
You pay:
Preferred provider: Nothing
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 41-43
Medical services provided by physicians, specialists and other healthcare professionals: Professional 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): 37
Medical services provided by physicians, specialists and other healthcare professionals: Diagnostic and treatment services provided in the office
You pay:
Preferred provider: 30%* of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 38
Medical services provided by physicians, specialists and other healthcare professionals: Telehealth services
You pay:
Preferred Telehealth Provider: Nothing
Non-preferred (Participating/Non-participating): You pay all charges
Page(s): 37, 81
Services provided by a hospital: Inpatient
You pay:
Preferred: 30%* of the Plan allowance (deductible applies)
Non-preferred (Member/Non-member): You pay all charges
Page(s): 65-66
Services provided by a hospital: Outpatient
You pay:
Preferred: 30%* of the Plan allowance (deductible applies)
Non-preferred (Member/Non-member): You pay all charges
Page(s): 68-71