2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Table of Contents
Page 2
Table of Contents
Page 2
• Emergency inpatient admission - 26
• Maternity care - 26
• If your facility stay needs to be extended - 26
• If your treatment needs to be extended - 26
If you disagree with our pre-service claim decision - 26
• To reconsider a non-urgent care claim - 26
• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 27
• Maternity care - 26
• If your facility stay needs to be extended - 26
• If your treatment needs to be extended - 26
If you disagree with our pre-service claim decision - 26
• To reconsider a non-urgent care claim - 26
• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 27
Section 4. Your Costs for Covered Services - 28
Cost-share/Cost-sharing - 28
Copayment - 28
Deductible - 28
Coinsurance - 29
If your provider routinely waives your cost - 29
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing — Know Your Rights - 32
Your costs for other care - 32
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 33
Carryover - 34
If we overpay you - 34
When Government facilities bill us - 34
Copayment - 28
Deductible - 28
Coinsurance - 29
If your provider routinely waives your cost - 29
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing — Know Your Rights - 32
Your costs for other care - 32
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 33
Carryover - 34
If we overpay you - 34
When Government facilities bill us - 34
Section 5. Benefits - 35
Non-PSHB Benefits Available to Plan Members - 135
Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover - 136
Section 7. Filing a Claim for Covered Services - 138
Section 8. The Disputed Claims Process - 142
Section 8(a). Medicare PDP EGWP Disputed Claims Process - 145
Section 9. Coordinating Benefits With Medicare and Other Coverage - 146
Non-PSHB Benefits Available to Plan Members - 135
Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover - 136
Section 7. Filing a Claim for Covered Services - 138
Section 8. The Disputed Claims Process - 142
Section 8(a). Medicare PDP EGWP Disputed Claims Process - 145
Section 9. Coordinating Benefits With Medicare and Other Coverage - 146
When you have other health coverage - 146
• TRICARE and CHAMPVA - 146
• Workers’ Compensation - 147
• Medicaid - 147
When other Government agencies are responsible for your care - 147
When others are responsible for injuries - 147
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 148
Clinical trials - 148
When you have Medicare - 149
• The Original Medicare Plan (Part A or Part B) - 149
• Tell us about your Medicare coverage - 150
• Private contract with your physician - 150
• Medicare Advantage (Part C) - 150
• Medicare prescription drug coverage (Part D) - 151
• Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) - 151
• Medicare prescription drug coverage (Part B) - 152
When you are age 65 or over and do not have Medicare - 154
Physicians Who Opt-Out of Medicare - 155
When you have the Original Medicare Plan (Part A, Part B, or both) - 155
• TRICARE and CHAMPVA - 146
• Workers’ Compensation - 147
• Medicaid - 147
When other Government agencies are responsible for your care - 147
When others are responsible for injuries - 147
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 148
Clinical trials - 148
When you have Medicare - 149
• The Original Medicare Plan (Part A or Part B) - 149
• Tell us about your Medicare coverage - 150
• Private contract with your physician - 150
• Medicare Advantage (Part C) - 150
• Medicare prescription drug coverage (Part D) - 151
• Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) - 151
• Medicare prescription drug coverage (Part B) - 152
When you are age 65 or over and do not have Medicare - 154
Physicians Who Opt-Out of Medicare - 155
When you have the Original Medicare Plan (Part A, Part B, or both) - 155