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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 – Standard Option
Summary of Benefits – Basic Option
2025 Rate Information
 
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2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits

Section 5(e). Mental Health and Substance Use Disorder Benefits
Not Covered (Inpatient or Outpatient)

 

Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.

Benefit Description


Not Covered (Inpatient or Outpatient)
 
  • Educational or other counseling or training services
     
  • Services performed by a noncovered provider
     
  • Testing for and treatment of learning disabilities and intellectual disability
     
  • Inpatient services performed or billed by residential treatment centers, except as described in Sections 5(a) and 5(e)
     
  • Services performed or billed by schools, halfway houses, group homes or members of their staffs

    Note: We cover professional services as described in this section
     when they are provided and billed by a covered professional provider acting within the scope of their license.

     
  • Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present
     
  • Services performed or billed by residential therapeutic camps (e.g., wilderness camps, Outward Bound, etc.)
     
  • Hippotherapy/equine therapy (exercise on horseback)
     
  • Light boxes
     
  • Custodial or long term care (see Definitions)
     
  • Costs associated with enabling or maintaining providers’ telehealth (telemedicine) technologies, non-interactive telecommunication such as email communications, or asynchronous store-and-forward telehealth services


Standard Option - You Pay
All charges

Basic Option - You Pay
All charges
 

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