Section 4. Your Costs for Covered Services

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2025 PSHB FEP Blue Focus brochure

Cover Page and Inside Cover

Table of Contents

Introduction/Plain Language/Advisory

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

Summary of Benefits – Standard Option

Summary of Benefits – Basic Option

2025 Rate Information

Blue Cross and Blue Shield Service Benefit Plan Brochure - 2025

PSHB Standard and Basic Options

Section 4. Your Costs for Covered Services

Cost share/Cost-sharing

If your provider routinely waives your cost

Differences between our allowance and the bill

Important Notice About Surprise Billing — Know Your Rights

Your costs for other care

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments

If we overpay you

When Government facilities bill us

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