Section 4. Your Costs for Covered Services

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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(g). Dental Benefits

5(h). Wellness and Other Special Features

5(i). Services, Drugs, and Supplies Provided Overseas

Non-FEHB Benefits Available to Plan Members

Summary of Benefits – Standard Option

Summary of Benefits – Basic Option

2025 Rate Information

Entire brochure in page-number order

Blue Cross and Blue Shield Service Benefit Plan Brochure - 2025

FEHB 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

The Federal Flexible Spending Account Program – FSAFEDS

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