Blue Cross and Blue Shield Service Benefit Plan Brochure - 2026

PSHB FEP Blue Focus

 

Document list

Document Name Document Number
Cover Page PFBF26.00.1.1
Inside cover PFBF26.00.1.2
Table of Contents PFBF26.00.1.3
Introduction PFBF26.00.2.1
Plain Language PFBF26.00.2.2
Stop Healthcare Fraud PFBF26.00.2.3
Discrimination is Against the Law PFBF26.00.2.4
Preventing Medical Mistakes PFBF26.00.2.5
No pre-existing condition limitation PFBF26.00.3.1.1
Minimum essential coverage (MEC) PFBF26.00.3.1.2
Minimum value standard PFBF26.00.3.1.3
Where you can get information about enrolling in the PSHB Program PFBF26.00.3.1.4
Enrollment types available for you and your family PFBF26.00.3.1.5
Family member coverage PFBF26.00.3.1.6
Children's Equity Act PFBF26.00.3.1.7
Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) PFBF26.00.3.1.7.1
When benefits and premiums start PFBF26.00.3.1.8
When you retire PFBF26.00.3.1.9
When PSHB coverage ends PFBF26.00.3.2.1
Upon divorce PFBF26.00.3.2.2
Medicare PDP EGWP PFBF26.00.3.2.2.1
Temporary Continuation of Coverage (TCC) PFBF26.00.3.2.3
Finding replacement coverage PFBF26.00.3.2.4
Health Insurance Marketplace PFBF26.00.3.2.5
Section 1. How This Plan Works PFBF26.01.0
General features of FEP Blue Focus/We have a Preferred Provider Organization (PPO) PFBF26.01.1
How we pay professional and facility providers PFBF26.01.2
Your rights and responsibilities PFBF26.01.3
Your medical and claims records are confidential PFBF26.01.4
Section 2. Changes for 2026 PFBF26.02
Identification cards PFBF26.03.1
Where you get covered care PFBF26.03.2.0
Balance Billing Protection PFBF26.03.2.01
Covered professional providers PFBF26.03.2.1
Covered facility providers PFBF26.03.2.2
What you must do to get covered care PFBF26.03.3.0
Transitional care PFBF26.03.3.1
If you are hospitalized when your enrollment begins PFBF26.03.3.2
You need prior Plan approval for certain services PFBF26.03.4.00
Inpatient hospital admission, inpatient residential treatment center admission PFBF26.03.4.01
Other services PFBF26.03.4.02
Special prior authorization situations related to coordination of benefits (COB) PFBF26.03.4.03
Prior notification - Maternity care PFBF26.03.4.04
How to request precertification for an admission or get approval for Other services PFBF26.03.4.05
Non-urgent care claims PFBF26.03.4.06
Urgent care claims PFBF26.03.4.07
Concurrent care claims PFBF26.03.4.08
Emergency inpatient admission PFBF26.03.4.09
Maternity care PFBF26.03.4.10
If your hospital stay needs to be extended PFBF26.03.4.11
If your treatment needs to be extended PFBF26.03.4.12
If you disagree with our pre-service claim decision PFBF26.03.5.0
To reconsider a non-urgent care claim PFBF26.03.5.1
To reconsider an urgent care claim PFBF26.03.5.2
To file an appeal with OPM PFBF26.03.5.3
Cost-share/Cost-sharing PFBF26.04.01
Copayment PFBF26.04.02
Deductible PFBF26.04.03
Coinsurance PFBF26.04.04
If your provider routinely waives your cost PFBF26.04.05
Waivers PFBF26.04.06
Differences between our allowance and the bill PFBF26.04.07
Important Notice About Surprise Billing – Know Your Rights PFBF26.04.08
Your costs for other care PFBF26.04.09
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments PFBF26.04.10
Carryover PFBF26.04.11
If we overpay you PFBF26.04.12
When Government facilities bill us PFBF26.04.13
Section 5. Benefits [Table of Contents] PFBF26.05.01
Section 5. FEP Blue Focus Overview PFBF26.05.02
Section 5(a). Overview PFBF26.05a.0
Diagnostic and Treatment Services PFBF26.05a.01
Lab, X-ray and Other Diagnostic Tests PFBF26.05a.02
Preventive Care, Adult PFBF26.05a.03
Preventive Care, Child PFBF26.05a.04
Maternity Care PFBF26.05a.05
Family Planning PFBF26.05a.06
Reproductive Services PFBF26.05a.07
Allergy Care PFBF26.05a.08
Treatment Therapies PFBF26.05a.09
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy PFBF26.05a.10
Hearing Services PFBF26.05a.11
Vision Services (Testing, Treatment, and Supplies) PFBF26.05a.12
Foot Care PFBF26.05a.13
Orthopedic and Prosthetic Devices PFBF26.05a.14
Durable Medical Equipment (DME) PFBF26.05a.15
Medical Supplies PFBF26.05a.16
Home Health Services PFBF26.05a.17
Alternative/Manipulative Treatment PFBF26.05a.18
Educational Classes and Programs PFBF26.05a.19
Section 5(b). Overview PFBF26.05b.0
Surgical Procedures PFBF26.05b.1
Reconstructive Surgery PFBF26.05b.2
Oral and Maxillofacial Surgery PFBF26.05b.3
Organ/Tissue Transplants PFBF26.05b.4
Anesthesia PFBF26.05b.5
Section 5(c). Overview PFBF26.05c.0
Inpatient Hospital PFBF26.05c.1
Maternity - Facility PFBF26.05c.2
Outpatient Hospital or Ambulatory Surgical Center PFBF26.05c.3
Residential Treatment Center PFBF26.05c.4
Extended Care Benefits/Skilled Nursing Care Facility Benefits PFBF26.05c.5
Hospice Care PFBF26.05c.6
Ambulance PFBF26.05c.7
Section 5(d). Overview PFBF26.05d.0
Accidental Injury PFBF26.05d.1
Medical Emergency PFBF26.05d.2
Ambulance PFBF26.05d.3
Section 5(e). Overview PFBF26.05e.0
Professional Services PFBF26.05e.1
Inpatient Hospital or Other Covered Facility PFBF26.05e.2
Residential Treatment Center PFBF26.05e.3
Outpatient Hospital or Other Covered Facility PFBF26.05e.4
Section 5(f). Overview PFBF26.05f.0
There are important features you should be aware of PFBF26.05f.01
Who can write your prescriptions PFBF26.05f.02
Where you can obtain them PFBF26.05f.03
What is covered PFBF26.05f.04
Generic equivalents PFBF26.05f.05
Disclosure of information PFBF26.05f.06
These are the dispensing limitations PFBF26.05f.07
Patient Safety and Quality Monitoring (PSQM) PFBF26.05f.08
Prior Approval PFBF26.05f.09
Medical Foods PFBF26.05f.10
Here is how to obtain your prescription drugs and supplies PFBF26.05f.11
Preferred retail pharmacies PFBF26.05f.12
Section 5(f). MPDP Overview PFBF26.05f.13
MPDP There are important features you should be aware of PFBF26.05f.14
MPDP Who can write your prescriptions PFBF26.05f.15
MPDP Where you can obtain prescription drugs PFBF26.05f.16
MPDP We have a managed formulary PFBF26.05f.17
MPDP These are the dispensing limitations PFBF26.05f.18
MPDP Prior Approval PFBF26.05f.19
MPDP Generic equivalents PFBF26.05f.20
MPDP How to obtain your prescription drugs and supplies PFBF26.05f.21
MPDP Medical Foods PFBF26.05f.22
MPDP Disclosure of information PFBF26.05f.23
MPDP Important contact information PFBF26.05f.24
MPDP PDP EGWP Catastrophic Maximums PFBF26.05f.25
MPDP Covered Drugs and Supplies PFBF26.05f.26
Over-the-counter (OTC) contraceptive drugs and devices PFBF26.05f.27
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network PFBF26.05f.28
Diabetic Meter Program PFBF26.05f.29
Medications to promote better health as recommended under the ACA PFBF26.05f.30
Generic medications to reduce breast cancer risk for women PFBF26.05f.31
Bowel preparation medications and antiretroviral therapy medications for HIV PFBF26.05f.32
Opioid Rescue Agents PFBF26.05f.33
Smoking and Tobacco Cessation Medications PFBF26.05f.34
Not Covered PFBF26.05f.35
Drugs From Other Sources PFBF26.05f.36
Section 5(g). Overview PFBF26.05g.0
Accidental Injury Benefit PFBF26.05g.1
Inpatient and Outpatient Facility Care PFBF26.05g.2
Health Tools PFBF26.05h.01
Services for the Deaf and Hearing Impaired PFBF26.05h.02
Web Accessibility for the Visually Impaired PFBF26.05h.03
Travel Benefit/Services Overseas PFBF26.05h.04
Healthy Families PFBF26.05h.05
Blue Health Assessment PFBF26.05h.06
Hypertension Management Program PFBF26.05h.07
MyBlue Customer eService PFBF26.05h.08
National Doctor & Hospital Finder PFBF26.05h.09
Care Management Programs PFBF26.05h.10
Flexible Benefits Option PFBF26.05h.11
Telehealth Services PFBF26.05h.12
Routine Annual Physical Incentive Program PFBF26.05h.13
The fepblue Mobile Application PFBF26.05h.14
Weight Loss Management Program PFBF26.05h.15
Section 5(i). Services, Drugs, and Supplies Provided Overseas PFBF26.05i.0
Non-PSHB Benefits Available to Plan Members PFBF26.05N.0
Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover PFBF26.06
Section 7. Filing a Claim for Covered Services PFBF26.07
Section 8. The Disputed Claims Process PFBF26.08
Section 8(a). Medicare PDP EGWP Disputed Claims Process PFBF26.08a
When you have other health coverage PFBF26.09.1.0
TRICARE and CHAMPVA PFBF26.09.1.1
Workers' Compensation PFBF26.09.1.2
Medicaid PFBF26.09.1.3
When other Government agencies are responsible for your care PFBF26.09.2
When others are responsible for injuries PFBF26.09.3
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) PFBF26.09.4
Clinical trials PFBF26.09.5
When you have Medicare PFBF26.09.6.1
The Original Medicare Plan (Part A or Part B) PFBF26.09.6.2
Tell us about your Medicare coverage PFBF26.09.6.3
Private contract with your physician PFBF26.09.6.4
Medicare Advantage (Part C) PFBF26.09.6.5
Medicare prescription drug coverage (Part D) PFBF26.09.6.6
Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) PFBF26.09.6.6.1
Medicare prescription drug coverage (Part B) PFBF26.09.6.7
Primary payor chart PFBF26.09.6.8
When you are age 65 or over and do not have Medicare PFBF26.09.7
Physicians Who Opt-Out of Medicare PFBF26.09.8
When you have the Original Medicare Plan (Part A, Part B, or both) PFBF26.09.9
Cost-share when Medicare is your primary payor PFBF26.09.95
Section 10. Definitions of Terms We Use in This Brochure PFBF26.10
Index PFBF26.11
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus - 2026 PFBF26.12
2026 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan PFBF26.13
Quick Links PFBF26.QL
Cover page PFBF26-000-1
Inside cover PFBF26-000-2
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