2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2023
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2023
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2023
Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a decision, please read this FEHB brochure.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
Basic Option does not provide benefits when you use Non-preferred providers. For a list of the exceptions to this requirement, see page 20. There is no deductible for Basic Option.
You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.fepblue.org/brochure.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
Basic Option does not provide benefits when you use Non-preferred providers. For a list of the exceptions to this requirement, see page 20. There is no deductible for Basic Option.
You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.fepblue.org/brochure.
Medical services provided by physicians: Diagnostic and treatment services provided in the office
PPO: Nothing for preventive care; $30 per office visit for primary care physicians and other healthcare professionals; $40 per office visit for specialists
Non-PPO: You pay all charges
39-46
Medical services provided by physicians: Telehealth services
PPO: Nothing for the first 2 visits per calendar year after the 2nd visit: $15 copayment per visit
Non-PPO: You pay all charges
39, 99
Services provided by a hospital: Inpatient
PPO: $250 per day up to $1,500 per admission
Non-PPO: You pay all charges
79-81
Services provided by a hospital: Outpatient
PPO: $150 per day per facility
Non-PPO: You pay all charges
81-85
Emergency benefits: Accidental injury
PPO: $35 copayment for urgent care; $250 copayment for emergency room care
Non-PPO: $250 copayment for emergency room care; you pay all charges for care in settings other than the emergency room
Ambulance transport services: $100 per day for ground ambulance; $150 per day for air or sea ambulance
95-96
Emergency benefits: Medical emergency
Same as for accidental injury
96-97
Mental health and substance use disorder treatment
PPO: Regular cost-sharing, such as $30 office visit copayment; $250 per day up to $1,500 per inpatient admission
Non-PPO: You pay all charges
98-102
Prescription drugs
Retail Pharmacy Program:
Dental care
PPO: $30 copayment per evaluation (exam, cleaning, and X-rays); most services limited to 2 per year; sealants for children up to age 16; $30 copayment for associated oral evaluations required due to accidental injury; regular benefits for covered oral and maxillofacial surgery
Non-PPO: You pay all charges
124
Wellness and other special features: Health Tools; Blue Health Assessment; MyBlue® Customer eService; Diabetes Management Incentive Program; National Doctor and Hospital Finder; Healthy Families; travel benefit/services overseas; Care Management Programs; and Flexible benefits option
See Section 5(h).
125-129
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
32-33
PPO: Nothing for preventive care; $30 per office visit for primary care physicians and other healthcare professionals; $40 per office visit for specialists
Non-PPO: You pay all charges
39-46
Medical services provided by physicians: Telehealth services
PPO: Nothing for the first 2 visits per calendar year after the 2nd visit: $15 copayment per visit
Non-PPO: You pay all charges
39, 99
Services provided by a hospital: Inpatient
PPO: $250 per day up to $1,500 per admission
Non-PPO: You pay all charges
79-81
Services provided by a hospital: Outpatient
PPO: $150 per day per facility
Non-PPO: You pay all charges
81-85
Emergency benefits: Accidental injury
PPO: $35 copayment for urgent care; $250 copayment for emergency room care
Non-PPO: $250 copayment for emergency room care; you pay all charges for care in settings other than the emergency room
Ambulance transport services: $100 per day for ground ambulance; $150 per day for air or sea ambulance
95-96
Emergency benefits: Medical emergency
Same as for accidental injury
96-97
Mental health and substance use disorder treatment
PPO: Regular cost-sharing, such as $30 office visit copayment; $250 per day up to $1,500 per inpatient admission
Non-PPO: You pay all charges
98-102
Prescription drugs
Retail Pharmacy Program:
- PPO: $15 generic/($10 if you have primary Medicare Part B)/$60 Preferred brand-name per prescription ($50 if you have primary Medicare Part B)/60% coinsurance ($90 minimum) for non-preferred brand-name drugs (50% ($60 minimum) if you have primary Medicare Part B)
- Non-PPO: You pay all charges
- $85 preferred specialty drug for a purchase of up to a 30-day supply; $110 non-preferred specialty drug for a purchase of up to a 30-day supply
- $20 generic/$100 Preferred brand-name/$125 non-preferred brand-name per prescription; up to a 90-day supply
Dental care
PPO: $30 copayment per evaluation (exam, cleaning, and X-rays); most services limited to 2 per year; sealants for children up to age 16; $30 copayment for associated oral evaluations required due to accidental injury; regular benefits for covered oral and maxillofacial surgery
Non-PPO: You pay all charges
124
Wellness and other special features: Health Tools; Blue Health Assessment; MyBlue® Customer eService; Diabetes Management Incentive Program; National Doctor and Hospital Finder; Healthy Families; travel benefit/services overseas; Care Management Programs; and Flexible benefits option
See Section 5(h).
125-129
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
- Self Only: Nothing after $6,500 (PPO) per contract per year
- Self Plus One: Nothing after $13,000 (PPO) per contract per year
- Self and Family: Nothing after $13,000 (PPO) per contract per year; nothing after $6,500 (PPO) per individual per year
Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
32-33