2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Table of Contents
Page 2
Table of Contents
Page 2
• Concurrent care claims - 25
• Emergency inpatient admission - 25
• Maternity care - 25
• 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 - 26
• To file an appeal with OPM - 26
• Emergency inpatient admission - 25
• Maternity care - 25
• 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 - 26
• To file an appeal with OPM - 26
Section 4. Your Costs for Covered Services - 27
Cost-share/Cost-sharing - 27
Copayment - 27
Deductible - 27
Coinsurance - 28
If your provider routinely waives your cost - 28
Waivers - 28
Differences between our allowance and the bill - 28
Important Notice About Surprise Billing — Know Your Rights - 31
Your costs for other care - 31
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 32
Carryover - 33
If we overpay you - 33
When Government facilities bill us - 33
The Federal Flexible Spending Account Program – FSAFEDS - 33
Copayment - 27
Deductible - 27
Coinsurance - 28
If your provider routinely waives your cost - 28
Waivers - 28
Differences between our allowance and the bill - 28
Important Notice About Surprise Billing — Know Your Rights - 31
Your costs for other care - 31
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 32
Carryover - 33
If we overpay you - 33
When Government facilities bill us - 33
The Federal Flexible Spending Account Program – FSAFEDS - 33
Section 5. Benefits - 34
Section 5. Standard and Basic Option Overview - 36
Non-FEHB Benefits Available to Plan Members - 133
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 134
Section 7. Filing a Claim for Covered Services - 136
Section 8. The Disputed Claims Process - 139
Section 9. Coordinating Benefits With Medicare and Other Coverage - 142
Section 8. The Disputed Claims Process - 139
Section 9. Coordinating Benefits With Medicare and Other Coverage - 142
When you have other health coverage - 142
• TRICARE and CHAMPVA - 142
• Workers’ Compensation - 143
• Medicaid - 143
When other Government agencies are responsible for your care - 143
When others are responsible for injuries - 143
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 145
Clinical trials - 145
When you have Medicare - 145
• The Original Medicare Plan (Part A or Part B) - 145
• Tell us about your Medicare coverage - 146
• Private contract with your physician - 146
• Medicare Advantage (Part C) - 147
• Medicare prescription drug coverage (Part D) - 147
• Medicare prescription drug coverage (Part B) - 147
When you are age 65 or over and do not have Medicare - 149
Physicians Who Opt-Out of Medicare - 150
When you have the Original Medicare Plan (Part A, Part B, or both) - 150
• TRICARE and CHAMPVA - 142
• Workers’ Compensation - 143
• Medicaid - 143
When other Government agencies are responsible for your care - 143
When others are responsible for injuries - 143
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 145
Clinical trials - 145
When you have Medicare - 145
• The Original Medicare Plan (Part A or Part B) - 145
• Tell us about your Medicare coverage - 146
• Private contract with your physician - 146
• Medicare Advantage (Part C) - 147
• Medicare prescription drug coverage (Part D) - 147
• Medicare prescription drug coverage (Part B) - 147
When you are age 65 or over and do not have Medicare - 149
Physicians Who Opt-Out of Medicare - 150
When you have the Original Medicare Plan (Part A, Part B, or both) - 150