Coverage information - 9
• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the PSHB Program - 9
• Enrollment types available for you and your family - 9
• Family Member Coverage - 10
• Children’s Equity Act - 11
• Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) - 11
• When benefits and premiums start - 11
• When you retire - 12
When you lose benefits - 12
• When PSHB coverage ends - 12
• Upon divorce - 12
• Medicare PDP EGWP - 12
• Temporary Continuation of Coverage (TCC) - 13
• Finding replacement coverage - 13
• Health Insurance Marketplace - 13

Section 1. How This Plan Works - 14

General features of our Standard and Basic Options - 14
We have a Preferred Provider Organization (PPO) - 14
How we pay professional and facility providers - 14
Your rights and responsibilities - 15
Your medical and claims records are confidential - 15

Section 2. New for 2025 - 16
Section 3. How You Get Care - 17

Identification cards - 17
Where you get covered care - 17
Balance Billing Protection - 17
• Covered professional providers - 17
• Covered facility providers - 17
What you must do to get covered care - 19
• Transitional care - 20
• If you are hospitalized when your enrollment begins - 20
You need prior Plan approval for certain services - 21
• Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility admission - 21
• Other services - 21
• Surgery by Non-participating providers under Standard Option - 24
How to request precertification for an admission or get prior authorization for Other services - 24
• Non-urgent care claims - 25
• Urgent care claims - 25
• Concurrent care claims - 25
• 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

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

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

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

Section 10. Definitions of Terms We Use in This Brochure - 157
Index - 167
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2025 - 169
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2025 - 171
2025 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan - 174