2026 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Table of Contents
Page 2

 

• Emergency inpatient admission - 26
• Maternity care - 26
• If your hospital 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 - 28
If your provider routinely waives your cost - 28
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing – Know Your Rights - 29
Your costs for other care - 30
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 30
Carryover - 31
If we overpay you - 31
When Government facilities bill us - 31
Section 5. FEP Blue Focus Benefits - 32
Non-PSHB Benefits Available to Plan Members - 108
Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover - 109
Section 7. Filing a Claim for Covered Services - 111
Section 8. The Disputed Claims Process - 114
Section 8(a). Medicare PDP EGWP Disputed Claims Process - 117
Section 9. Coordinating Benefits With Medicare and Other Coverage - 118
When you have other health coverage - 118
• TRICARE and CHAMPVA - 118
• Workers’ Compensation - 119
• Medicaid - 119
When other Government agencies are responsible for your care - 119
When others are responsible for injuries - 119
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 120
Clinical trials - 120
When you have Medicare - 121
• The Original Medicare Plan (Part A or Part B) - 121
• Tell us about your Medicare coverage - 122
• Private contract with your physician - 122
• Medicare Advantage (Part C) - 122
• Medicare prescription drug coverage (Part D) - 123
• Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) - 123
• Medicare prescription drug coverage (Part B) - 123
When you are age 65 or over and do not have Medicare - 125
Physicians Who Opt-Out of Medicare - 126
When you have the Original Medicare Plan (Part A, Part B, or both) - 126
Section 10. Definitions of Terms We Use in This Brochure - 128
Index - 137
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus - 2026 - 139