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Cover page
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PSB25.00.1.1
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Inside cover
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PSB25.00.1.2
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Table of Contents
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PSB25.00.1.3
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Introduction
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PSB25.00.2.1
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Plain Language
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PSB25.00.2.2
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Stop Healthcare Fraud!
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PSB25.00.2.3
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Discrimination is Against the Law
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PSB25.00.2.4
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Preventing Medical Mistakes
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PSB25.00.2.5
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No pre-existing condition limitation
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PSB25.00.3.1.1
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Minimum essential coverage (MEC)
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PSB25.00.3.1.2
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Minimum value standard
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PSB25.00.3.1.3
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Where you can get information about enrolling in the PSHB Program
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PSB25.00.3.1.4
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Enrollment types available for you and your family
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PSB25.00.3.1.5
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Family member coverage
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PSB25.00.3.1.6
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Children's Equity Act
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PSB25.00.3.1.7
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Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP)
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PSB25.00.3.1.7.1
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When benefits and premiums start
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PSB25.00.3.1.8
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When you retire
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PSB25.00.3.1.9
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When PSHB coverage ends
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PSB25.00.3.2.1
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Upon divorce
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PSB25.00.3.2.2
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Medicare PDP EGWP
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PSB25.00.3.2.2.1
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Temporary Continuation of Coverage (TCC)
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PSB25.00.3.2.3
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Finding replacement coverage
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PSB25.00.3.2.4
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Health Insurance Marketplace
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PSB25.00.3.2.5
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Section 1. How This Plan Works
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PSB25.01.0
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General features of our Standard and Basic Options//We have a Preferred Provider Organization (PPO)
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PSB25.01.1
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How we pay professional and facility providers
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PSB25.01.2
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Your rights and responsibilities
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PSB25.01.3
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Your medical and claims records are confidential
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PSB25.01.4
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Section 2. New for 2025
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PSB25.02.0
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Identification cards
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PSB25.03.1
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Where you get covered care
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PSB25.03.2.0
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Balance Billing Protection
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PSB25.03.2.05
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Covered professional providers
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PSB25.03.2.1
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Covered facility providers
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PSB25.03.2.2
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What you must do to get covered care
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PSB25.03.3.0
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Transitional care
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PSB25.03.3.1
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If you are hospitalized when your enrollment begins
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PSB25.03.3.2
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You need prior Plan Approval for certain services
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PSB25.03.4.00
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Inpatient hospital, residential treatment center, or skilled nursing facility admission
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PSB25.03.4.01
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Other services
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PSB25.03.4.02
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Surgery by Non-participating providers under Standard Option
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PSB25.03.4.03
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How to request precertification for an admission or get approval for Other services
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PSB25.03.4.04
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Non-urgent care claims
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PSB25.03.4.05
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Urgent care claims
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PSB25.03.4.06
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Concurrent care claims
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PSB25.03.4.07
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Emergency inpatient admission
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PSB25.03.4.08
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Maternity care
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PSB25.03.4.09
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If your facility stay needs to be extended
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PSB25.03.4.10
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If your treatment needs to be extended
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PSB25.03.4.11
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If you disagree with our pre-service claim decision
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PSB25.03.5.0
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To reconsider a non-urgent care claim
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PSB25.03.5.1
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To reconsider an urgent care claim
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PSB25.03.5.2
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To file an appeal with OPM
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PSB25.03.5.3
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Cost share/Cost-sharing
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PSB25.04.01
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Copayment
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PSB25.04.02
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Deductible
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PSB25.04.03
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Coinsurance
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PSB25.04.04
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If your provider routinely waives your cost
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PSB25.04.05
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Waivers
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PSB25.04.06
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Differences between our allowance and the bill
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PSB25.04.07
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Important Notice About Surprise Billing — Know Your Rights
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PSB25.04.08
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Your costs for other care
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PSB25.04.09
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Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments
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PSB25.04.10
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Carryover
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PSB25.04.11
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If we overpay you
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PSB25.04.12
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When Government facilities bill us
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PSB25.04.13
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Section 5. Benefits
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PSB25.05.01
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Section 5. Standard and Basic Option Overview
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PSB25.05.02
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Section 5(a). Overview
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PSB25.05a.0
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Diagnostic and Treatment Services
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PSB25.05a.01
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Lab, X-ray and Other Diagnostic Tests
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PSB25.05a.02
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Preventive Care, Adult
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PSB25.05a.03
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Preventive Care, Child
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PSB25.05a.04
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Maternity Care
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PSB25.05a.05
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Family Planning
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PSB25.05a.06
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Reproductive Services
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PSB25.05a.07
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Allergy Care
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PSB25.05a.08
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Treatment Therapies
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PSB25.05a.09
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Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy
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PSB25.05a.10
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Hearing Services (Testing, Treatment, and Supplies)
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PSB25.05a.11
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Vision Services (Testing, Treatment, and Supplies)
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PSB25.05a.12
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Foot Care
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PSB25.05a.13
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Orthopedic and Prosthetic Devices
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PSB25.05a.14
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Durable Medical Equipment (DME)
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PSB25.05a.15
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Medical Supplies
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PSB25.05a.16
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Home Health Services
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PSB25.05a.17
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Manipulative Treatment
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PSB25.05a.18
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Alternative Treatments
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PSB25.05a.19
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Educational Classes and Programs
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PSB25.05a.20
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Section 5(b). Overview
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PSB25.05b.0
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Surgical Procedures
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PSB25.05b.1
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Reconstructive Surgery
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PSB25.05b.2
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Oral and Maxillofacial Surgery
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PSB25.05b.3
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Organ/Tissue Transplants
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PSB25.05b.4
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Anesthesia
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PSB25.05b.5
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Section 5(c). Overview
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PSB25.05c.0
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Inpatient Hospital
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PSB25.05c.1
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Outpatient Hospital or Ambulatory Surgical Center
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PSB25.05c.2
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Blue Distinction Specialty Care
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PSB25.05c.3
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Residential Treatment Center
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PSB25.05c.4
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Extended Care Benefits/Skilled Nursing Care Facility Benefits
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PSB25.05c.5
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Hospice Care
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PSB25.05c.6
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Ambulance
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PSB25.05c.7
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Section 5(d). Overview
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PSB25.05d.0
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Accidental Injury
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PSB25.05d.1
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Medical Emergency
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PSB25.05d.2
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Ambulance
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PSB25.05d.3
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Section 5(e). Overview
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PSB25.05e.0
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Professional Services
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PSB25.05e.1
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Inpatient Hospital or Other Covered Facility
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PSB25.05e.2
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Residential Treatment Center
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PSB25.05e.3
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Outpatient Hospital or Other Covered Facility
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PSB25.05e.4
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Not Covered (Inpatient or Outpatient)
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PSB25.05e.5
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Section 5(f). Overview
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PSB25.05f.0
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There are important features you should be aware of
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PSB25.05f.01
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Who can write your prescriptions
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PSB25.05f.02
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Where you can obtain them
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PSB25.05f.03
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What is covered
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PSB25.05f.04
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Generic equivalents
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PSB25.05f.05
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Disclosure of information
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PSB25.05f.06
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These are the dispensing limitations
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PSB25.05f.07
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Patient Safety and Quality Monitoring (PSQM)
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PSB25.05f.08
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Prior Approval
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PSB25.05f.09
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Standard Option Generic Incentive Program
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PSB25.05f.10
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Medical Foods
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PSB25.05f.11
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Here is how to obtain your prescription drugs and supplies
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PSB25.05f.12
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Preferred Retail Pharmacies
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PSB25.05f.13
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Non-preferred Retail Pharmacies
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PSB25.05f.14
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Mail Service Prescription Drug Program
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PSB25.05f.15
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Specialty Drug Pharmacy Program
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PSB25.05f.16
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Asthma Medications
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PSB25.05f.17
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Other Preferred Diabetic Medications, Test Strips, and Supplies
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PSB25.05f.18
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Diabetic Meter Program
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PSB25.05f.19
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Section 5(f)(a). MPDP Overview
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PSB25.05f.20
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MPDP There are important features you should be aware of
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PSB25.05f.21
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MPDP Who can write your prescriptions
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PSB25.05f.22
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MPDP Where you can obtain prescription drugs
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PSB25.05f.23
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MPDP We use a managed formulary
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PSB25.05f.24
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MPDP These are the dispensing limitations
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PSB25.05f.25
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MPDP Prior Approval
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PSB25.05f.26
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MPDP Generic equivalents
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PSB25.05f.27
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MPDP How to obtain your prescription drugs and supplies
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PSB25.05f.28
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MPDP Medical Foods
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PSB25.05f.29
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MPDP When you do have to file a claim
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PSB25.05f.30
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MPDP Disclosure of information
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PSB25.05f.31
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MPDP Important Contact Information
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PSB25.05f.31.1
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MPDP Catastrophic Maximums
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PSB25.05f.32
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MPDP Retail Pharmacies
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PSB25.05f.33
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MPDP Mail Service Prescription Drug Program
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PSB25.05f.34
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MPDP Asthma Medications
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PSB25.05f.35
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MPDP Other Preferred Diabetic Medications, Test Strips, and Supplies
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PSB25.05f.36
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Smoking and Tobacco Cessation Medications
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PSB25.05f.37
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Anti-hypertensive Medications
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PSB25.05f.38
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Over-the-counter (OTC) contraceptive drugs and devices
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PSB25.05f.39
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Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network
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PSB25.05f.40
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Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
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PSB25.05f.41
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Medications to promote better health as recommended under the ACA
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PSB25.05f.42
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Generic medications to reduce breast cancer risk for women
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PSB25.05f.43
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Bowel preparation medications and antiretroviral therapy medications for HIV
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PSB25.05f.44
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Opioid Reversal Agents: Tier 1 medications including generic naloxone spray and injectable
|
PSB25.05f.45
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Not Covered
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PSB25.05f.46
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Drugs From Other Sources
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PSB25.05f.47
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Section 5(g). Overview
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PSB25.05g.0
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Accidental Injury Benefit
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PSB25.05g.1
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Dental Benefits
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PSB25.05g.2
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Health Tools
|
PSB25.05h.01
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Services for the Deaf and Hearing Impaired
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PSB25.05h.02
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Web Accessibility for the Visually Impaired
|
PSB25.05h.03
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Travel Benefit/Services Overseas
|
PSB25.05h.04
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Healthy Families
|
PSB25.05h.05
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Diabetes Management Program
|
PSB25.05h.06
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Blue Health Assessment
|
PSB25.05h.07
|
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Hypertension Management Program
|
PSB25.05h.08
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Pregnancy Care Incentive Program
|
PSB25.05h.09
|
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Annual Incentive Limitation
|
PSB25.05h.10
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Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B
|
PSB25.05h.11
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MyBlue Customer eService
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PSB25.05h.12
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National Doctor & Hospital Finder
|
PSB25.05h.13
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Care Management Programs
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PSB25.05h.14
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Flexible Benefits Option
|
PSB25.05h.15
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Telehealth Services
|
PSB25.05h.16
|
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The fepblue Mobile Application
|
PSB25.05h.17
|
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Section 5(i). Services, Drugs, and Supplies Provided Overseas
|
PSB25.05i.0
|
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Non-PSHB Benefits Available to Plan Members
|
PSB25.05N.0
|
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Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover
|
PSB25.06
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Section 7. Filing a Claim for Covered Services
|
PSB25.07
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Section 8. The Disputed Claims Process
|
PSB25.08
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Section 8(a). Medicare PDP EGWP Disputed Claims Process
|
PSB25.08.a
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When you have other health coverage
|
PSB25.09.1.0
|
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TRICARE and CHAMPVA
|
PSB25.09.1.1
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Workers' Compensation
|
PSB25.09.1.2
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Medicaid
|
PSB25.09.1.3
|
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When other Government agencies are responsible for your care
|
PSB25.09.2
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When others are responsible for injuries
|
PSB25.09.3
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When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP)
|
PSB25.09.4
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Clinical trials
|
PSB25.09.5
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When you have Medicare
|
PSB25.09.6.1
|
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The Original Medicare Plan (Part A or Part B)
|
PSB25.09.6.2
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Tell us about your Medicare coverage
|
PSB25.09.6.3
|
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Private contract with your physician
|
PSB25.09.6.4
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Medicare Advantage (Part C)
|
PSB25.09.6.5
|
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Medicare prescription drug coverage (Part D)
|
PSB25.09.6.6
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Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP)
|
PSB25.09.6.6.1
|
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Medicare prescription drug coverage (Part B)
|
PSB25.09.6.7
|
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Primary payor chart
|
PSB25.09.6.8
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When you are age 65 or over and do not have Medicare
|
PSB25.09.7
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Physicians Who Opt-Out of Medicare
|
PSB25.09.8
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When you have the Original Medicare Plan (Part A, Part B, or both)
|
PSB25.09.9
|
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Cost-share when Medicare is your primary payor
|
PSB25.09.95
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Section 10. Definitions of Terms We Use in This Brochure
|
PSB25.10
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Index
|
PSB25.11
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Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2025
|
PSB25.12.1
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Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2025
|
PSB25.12.2
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2025 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan
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PSB25.13
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Quick Links
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PSB25.QL
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Cover page
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PSB25-000-1
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Inside cover
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PSB25-000-2
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109
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PSB25-109
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110
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PSB25-110
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111
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PSB25-111
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112
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PSB25-112
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113
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PSB25-113
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114
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PSB25-114
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115
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PSB25-115
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116
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PSB25-116
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117
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PSB25-117
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118
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PSB25-118
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119
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PSB25-119
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120
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PSB25-120
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121
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PSB25-121
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122
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PSB25-122
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123
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124
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PSB25-124
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125
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PSB25-125
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126
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PSB25-126
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127
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128
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PSB25-128
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129
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PSB25-129
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130
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PSB25-130
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131
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PSB25-131
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132
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PSB25-132
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133
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PSB25-133
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134
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PSB25-134
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135
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PSB25-135
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136
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PSB25-136
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137
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PSB25-137
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138
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PSB25-138
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139
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PSB25-139
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140
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PSB25-140
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141
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PSB25-141
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142
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PSB25-142
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143
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PSB25-143
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144
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PSB25-144
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145
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PSB25-145
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146
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PSB25-146
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147
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PSB25-147
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148
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PSB25-148
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149
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PSB25-149
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150
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PSB25-150
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151
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PSB25-151
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152
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PSB25-152
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153
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PSB25-153
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154
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PSB25-154
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155
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PSB25-155
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156
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PSB25-156
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157
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PSB25-157
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158
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PSB25-158
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159
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PSB25-159
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160
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PSB25-160
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161
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PSB25-161
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162
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PSB25-162
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163
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PSB25-163
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164
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PSB25-164
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165
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PSB25-165
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166
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PSB25-166
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167
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PSB25-167
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168
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PSB25-168
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169
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PSB25-169
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170
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PSB25-170
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171
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PSB25-171
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172
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PSB25-172
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173
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PSB25-173
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174
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PSB25-174
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