Blue Cross and Blue Shield Service Benefit Plan Brochure - 2025

PSHB FEP Blue Focus

 

Document list

Document Name Document Number
Cover Page PFBF25.00.1.1
Inside cover PFBF25.00.1.2
Table of Contents PFBF25.00.1.3
Introduction PFBF25.00.2.1
Plain Language PFBF25.00.2.2
Stop Healthcare Fraud PFBF25.00.2.3
Discrimination is Against the Law PFBF25.00.2.4
Preventing Medical Mistakes PFBF25.00.2.5
No pre-existing condition limitation PFBF25.00.3.1.1
Minimum essential coverage (MEC) PFBF25.00.3.1.2
Minimum value standard PFBF25.00.3.1.3
Where you can get information about enrolling in the PSHB Program PFBF25.00.3.1.4
Enrollment types available for you and your family PFBF25.00.3.1.5
Family member coverage PFBF25.00.3.1.6
Children's Equity Act PFBF25.00.3.1.7
Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) PFBF25.00.3.1.7.1
When benefits and premiums start PFBF25.00.3.1.8
When you retire PFBF25.00.3.1.9
When PSHB coverage ends PFBF25.00.3.2.1
Upon divorce PFBF25.00.3.2.2
Medicare PDP EGWP PFBF25.00.3.2.2.1
Temporary Continuation of Coverage (TCC) PFBF25.00.3.2.3
Finding replacement coverage PFBF25.00.3.2.4
Health Insurance Marketplace PFBF25.00.3.2.5
Section 1. How This Plan Works PFBF25.01.0
General features of FEP Blue Focus/We have a Preferred Provider Organization (PPO) PFBF25.01.1
How we pay professional and facility providers PFBF25.01.2
Your rights and responsibilities PFBF25.01.3
Your medical and claims records are confidential PFBF25.01.4
Section 2. New for 2025 PFBF25.02
Identification cards PFBF25.03.1
Where you get covered care PFBF25.03.2.0
Balance Billing Protection PFBF25.03.2.01
Covered professional providers PFBF25.03.2.1
Covered facility providers PFBF25.03.2.2
What you must do to get covered care PFBF25.03.3.0
Transitional care PFBF25.03.3.1
If you are hospitalized when your enrollment begins PFBF25.03.3.2
You need prior Plan approval for certain services PFBF25.03.4.00
Inpatient hospital admission, inpatient residential treatment center admission PFBF25.03.4.01
Other services PFBF25.03.4.02
Special prior authorization situations related to coordination of benefits (COB) PFBF25.03.4.03
Prior notification - Maternity care PFBF25.03.4.04
How to request precertification for an admission or get approval for Other services PFBF25.03.4.05
Non-urgent care claims PFBF25.03.4.06
Urgent care claims PFBF25.03.4.07
Concurrent care claims PFBF25.03.4.08
Emergency inpatient admission PFBF25.03.4.09
Maternity care PFBF25.03.4.10
If your hospital stay needs to be extended PFBF25.03.4.11
If your treatment needs to be extended PFBF25.03.4.12
If you disagree with our pre-service claim decision PFBF25.03.5.0
To reconsider a non-urgent care claim PFBF25.03.5.1
To reconsider an urgent care claim PFBF25.03.5.2
To file an appeal with OPM PFBF25.03.5.3
Cost-share/Cost-sharing PFBF25.04.01
Copayment PFBF25.04.02
Deductible PFBF25.04.03
Coinsurance PFBF25.04.04
If your provider routinely waives your cost PFBF25.04.05
Waivers PFBF25.04.06
Differences between our allowance and the bill PFBF25.04.07
Important Notice About Surprise Billing – Know Your Rights PFBF25.04.08
Your costs for other care PFBF25.04.09
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments PFBF25.04.10
Carryover PFBF25.04.11
If we overpay you PFBF25.04.12
When Government facilities bill us PFBF25.04.13
Section 5. Benefits - Table of Contents PFBF25.05.01
Section 5. FEP Blue Focus Overview PFBF25.05.02
Section 5(a). Overview PFBF25.05a.0
Diagnostic and Treatment Services PFBF25.05a.01
Lab, X-ray and Other Diagnostic Tests PFBF25.05a.02
Preventive Care, Adult PFBF25.05a.03
Preventive Care, Child PFBF25.05a.04
Maternity Care PFBF25.05a.05
Family Planning PFBF25.05a.06
Reproductive Services PFBF25.05a.07
Allergy Care PFBF25.05a.08
Treatment Therapies PFBF25.05a.09
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy PFBF25.05a.10
Hearing Services PFBF25.05a.11
Vision Services (Testing, Treatment, and Supplies) PFBF25.05a.12
Foot Care PFBF25.05a.13
Orthopedic and Prosthetic Devices PFBF25.05a.14
Durable Medical Equipment (DME) PFBF25.05a.15
Medical Supplies PFBF25.05a.16
Home Health Services PFBF25.05a.17
Alternative/Manipulative Treatment PFBF25.05a.18
Educational Classes and Programs PFBF25.05a.19
Section 5(b). Overview PFBF25.05b.0
Surgical Procedures PFBF25.05b.1
Reconstructive Surgery PFBF25.05b.2
Oral and Maxillofacial Surgery PFBF25.05b.3
Organ/Tissue Transplants PFBF25.05b.4
Anesthesia PFBF25.05b.5
Section 5(c). Overview PFBF25.05c.0
Inpatient Hospital PFBF25.05c.1
Maternity - Facility PFBF25.05c.2
Outpatient Hospital or Ambulatory Surgical Center PFBF25.05c.3
Residential Treatment Center PFBF25.05c.4
Extended Care Benefits/Skilled Nursing Care Facility Benefits PFBF25.05c.5
Hospice Care PFBF25.05c.6
Ambulance PFBF25.05c.7
Section 5(d). Overview PFBF25.05d.0
Accidental Injury PFBF25.05d.1
Medical Emergency PFBF25.05d.2
Ambulance PFBF25.05d.3
Section 5(e). Overview PFBF25.05e.0
Professional Services PFBF25.05e.1
Inpatient Hospital or Other Covered Facility PFBF25.05e.2
Residential Treatment Center PFBF25.05e.3
Outpatient Hospital or Other Covered Facility PFBF25.05e.4
Section 5(f). Overview PFBF25.05f.0
There are important features you should be aware of PFBF25.05f.01
Who can write your prescriptions PFBF25.05f.02
Where you can obtain them PFBF25.05f.03
What is covered PFBF25.05f.04
Generic equivalents PFBF25.05f.05
Disclosure of information PFBF25.05f.06
These are the dispensing limitations PFBF25.05f.07
Patient Safety and Quality Monitoring (PSQM) PFBF25.05f.08
Prior Approval PFBF25.05f.09
Medical Foods PFBF25.05f.10
Here is how to obtain your prescription drugs and supplies PFBF25.05f.11
Preferred retail pharmacies PFBF25.05f.12
Section 5(f). MPDP Overview PFBF25.05f.13
MPDP There are important features you should be aware of PFBF25.05f.14
MPDP Who can write your prescriptions PFBF25.05f.15
MPDP Where you can obtain prescription drugs PFBF25.05f.16
MPDP We have a managed formulary PFBF25.05f.17
MPDP These are the dispensing limitations PFBF25.05f.18
MPDP Prior Approval PFBF25.05f.19
MPDP Generic equivalents PFBF25.05f.20
MPDP How to obtain your prescription drugs and supplies PFBF25.05f.21
MPDP Medical Foods PFBF25.05f.22
MPDP Disclosure of information PFBF25.05f.23
MPDP Important contact information PFBF25.05f.24
MPDP PDP EGWP Catastrophic Maximums PFBF25.05f.25
MPDP Covered Drugs and Supplies PFBF25.05f.26
Over-the-counter (OTC) contraceptive drugs and devices PFBF25.05f.27
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network PFBF25.05f.28
Diabetic Meter Program PFBF25.05f.29
Medications to promote better health as recommended under the ACA PFBF25.05f.30
Generic medications to reduce breast cancer risk for women PFBF25.05f.31
Bowel preparation medications and antiretroviral therapy medications for HIV PFBF25.05f.32
Opioid Reversal Agents: Tier 1 medications including Narcan nasal spray and naloxone PFBF25.05f.33
Smoking and Tobacco Cessation Medications PFBF25.05f.34
Not Covered PFBF25.05f.35
Drugs From Other Sources PFBF25.05f.36
Section 5(g). Overview PFBF25.05g.0
Accidental Injury Benefit PFBF25.05g.1
Inpatient and Outpatient Facility Care PFBF25.05g.2
Health Tools PFBF25.05h.01
Services for the Deaf and Hearing Impaired PFBF25.05h.02
Web Accessibility for the Visually Impaired PFBF25.05h.03
Travel Benefit/Services Overseas PFBF25.05h.04
Healthy Families PFBF25.05h.05
Blue Health Assessment PFBF25.05h.06
Hypertension Management Program PFBF25.05h.07
MyBlue Customer eService PFBF25.05h.08
National Doctor & Hospital Finder PFBF25.05h.09
Care Management Programs PFBF25.05h.10
Flexible Benefits Option PFBF25.05h.11
Telehealth Services PFBF25.05h.12
Routine Annual Physical Incentive Program PFBF25.05h.13
The fepblue Mobile Application PFBF25.05h.14
Section 5(i). Services, Drugs, and Supplies Provided Overseas PFBF25.05i.0
Non-PSHB Benefits Available to Plan Members PFBF25.05N.0
Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover PFBF25.06
Section 7. Filing a Claim for Covered Services PFBF25.07
Section 8. The Disputed Claims Process PFBF25.08
Section 8(a). Medicare PDP EGWP Disputed Claims Process PFBF25.08a
When you have other health coverage PFBF25.09.1.0
TRICARE and CHAMPVA PFBF25.09.1.1
Workers' Compensation PFBF25.09.1.2
Medicaid PFBF25.09.1.3
When other Government agencies are responsible for your care PFBF25.09.2
When others are responsible for injuries PFBF25.09.3
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) PFBF25.09.4
Clinical trials PFBF25.09.5
When you have Medicare PFBF25.09.6.1
The Original Medicare Plan (Part A or Part B) PFBF25.09.6.2
Tell us about your Medicare coverage PFBF25.09.6.3
Private contract with your physician PFBF25.09.6.4
Medicare Advantage (Part C) PFBF25.09.6.5
Medicare prescription drug coverage (Part D) PFBF25.09.6.6
Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) PFBF25.09.6.6.1
Medicare prescription drug coverage (Part B) PFBF25.09.6.7
Primary payor chart PFBF25.09.6.8
When you are age 65 or over and do not have Medicare PFBF25.09.7
Physicians Who Opt-Out of Medicare PFBF25.09.8
When you have the Original Medicare Plan (Part A, Part B, or both) PFBF25.09.9
Cost-share when Medicare is your primary payor PFBF25.09.95
Section 10. Definitions of Terms We Use in This Brochure PFBF25.10
Index PFBF25.11
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus - 2025 PFBF25.12
2025 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan PFBF25.13
Quick Links PFBF25.QL
Cover page PFBF25-000-1
Inside cover PFBF25-000-2
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