2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Table of Contents
Page 2

 

• Concurrent care claims - 26
• Emergency inpatient admission - 26
• Maternity care - 26
• If your facility stay needs to be extended - 27
• If your treatment needs to be extended - 27
If you disagree with our pre-service claim decision - 27
• To reconsider a non-urgent care claim - 27
• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 27
Section 4. Your Costs for Covered Services - 28
Cost-share/Cost-sharing - 28
Copayment - 28
Deductible - 28
Coinsurance - 29
If your provider routinely waives your cost - 29
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing — Know Your Rights - 32
Your costs for other care - 32
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 33
Carryover - 33
If we overpay you - 34
When Government facilities bill us - 34
The Federal Flexible Spending Account Program – FSAFEDS - 34
Section 5. Benefits - 35
Section 5. Standard and Basic Option Overview - 37
Non-FEHB Benefits Available to Plan Members - 132
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 133
Section 7. Filing a Claim for Covered Services - 135
Section 8. The Disputed Claims Process - 138
Section 9. Coordinating Benefits With Medicare and Other Coverage - 141
When you have other health coverage - 141
• TRICARE and CHAMPVA - 141
• Workers’ Compensation - 142
• Medicaid - 142
When other Government agencies are responsible for your care - 142
When others are responsible for injuries - 142
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 144
Clinical trials - 144
When you have Medicare - 144
• The Original Medicare Plan (Part A or Part B) - 144
• Tell us about your Medicare coverage - 145
• Private contract with your physician - 145
• Medicare Advantage (Part C) - 146
• Medicare prescription drug coverage (Part D) - 146
• Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) - 146
• Medicare prescription drug coverage (Part B) - 146
When you are age 65 or over and do not have Medicare - 148
Physicians Who Opt-Out of Medicare - 149
When you have the Original Medicare Plan (Part A, Part B, or both) - 149
Section 10. Definitions of Terms We Use in This Brochure - 151