2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 156
Section 9. Coordinating Benefits With Medicare and Other Coverage
Page 156
Please review the following examples illustrating your cost-share liabilities when Medicare is your primary payor and your provider is in our network and participates with Medicare compared to what you pay without Medicare. Please do not rely on this chart alone but read all information in this section of the brochure. You can find more information about how our Plan coordinates with Medicare in our Medicare and You Guide for Federal Employees available online at www.fepblue.org.
Benefit Description: Deductible
Standard Option You Pay Without Medicare: $350-Self; $700-Family
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
Standard Option You Pay Without Medicare: $8,000-Self; $16,000-Family
Standard Option You Pay With Medicare Parts A & B: $8,000-Self; $16,000-Family
Basic Option You Pay Without Medicare: $7,500-Self; $15,000-Family
Basic Option With Medicare Parts A & B: $7,500-Self; $15,000-Family
Benefit Description: Part B Premium Reimbursement
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Parts A & B: N/A
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: $800
Benefit Description: Primary Care Provider
Standard Option You Pay Without Medicare: $30
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $35
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Specialist
Standard Option You Pay Without Medicare: $40
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $50
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Inpatient Hospital
Standard Option You Pay Without Medicare: $450
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $350/day up to $1,750
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Outpatient Hospital
Standard Option You Pay Without Medicare: 15% or $30 copayment
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: 30% or $35-$500 copayment
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Incentives Offered
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Parts A & B: N/A
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: N/A
Benefit Description: Deductible
Standard Option You Pay Without Medicare: $350-Self; $700-Family
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
Standard Option You Pay Without Medicare: $8,000-Self; $16,000-Family
Standard Option You Pay With Medicare Parts A & B: $8,000-Self; $16,000-Family
Basic Option You Pay Without Medicare: $7,500-Self; $15,000-Family
Basic Option With Medicare Parts A & B: $7,500-Self; $15,000-Family
Benefit Description: Part B Premium Reimbursement
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Parts A & B: N/A
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: $800
Benefit Description: Primary Care Provider
Standard Option You Pay Without Medicare: $30
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $35
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Specialist
Standard Option You Pay Without Medicare: $40
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $50
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Inpatient Hospital
Standard Option You Pay Without Medicare: $450
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $350/day up to $1,750
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Outpatient Hospital
Standard Option You Pay Without Medicare: 15% or $30 copayment
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: 30% or $35-$500 copayment
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Incentives Offered
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Parts A & B: N/A
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: N/A