Coverage information - 9
• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the PSHB Program - 9
• Enrollment types available for you and your family - 9
• Family Member Coverage - 10
• Children’s Equity Act - 11
• Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) - 11
• When benefits and premiums start - 11
• When you retire - 12
When you lose benefits - 12
• When PSHB coverage ends - 12
• Upon divorce - 12
• Medicare PDP EGWP - 12
• Temporary Continuation of Coverage (TCC) - 12
• Finding replacement coverage - 13
• Health Insurance Marketplace - 13

General features of FEP Blue Focus - 14
We have a Preferred Provider Organization (PPO) - 14
How we pay professional and facility providers - 14
Your rights and responsibilities - 15
Your medical and claims records are confidential - 15

Identification cards - 17
Where you get covered care - 17
Balance Billing Protection - 17
• Covered professional providers - 17
• Covered facility providers - 17
What you must do to get covered care - 19
• Transitional care - 19
• If you are hospitalized when your enrollment begins - 19
You need prior Plan approval for certain services - 20
• Inpatient hospital admission, inpatient residential treatment center admission - 20
• Other services - 20
• Special prior authorization situations related to coordination of benefits (COB) - 24
• Prior notification – Maternity care - 25
How to request precertification for an admission or get prior authorization for Other services - 25
• Non-urgent care claims - 25
• Urgent care claims - 26
• Concurrent care claims - 26
• 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

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

Non-PSHB Benefits Available to Plan Members - 108

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