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 Standard Option – 2023
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option – 2023
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard 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.
Below, an asterisk (*) means the item is subject to the $350 per person ($700 per Self Plus One or Self and Family enrollment) calendar year deductible. If you use a Non-PPO physician or other healthcare professional, you generally pay any difference between our allowance and the billed amount, in addition to any share of our allowance shown below.
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.
Below, an asterisk (*) means the item is subject to the $350 per person ($700 per Self Plus One or Self and Family enrollment) calendar year deductible. If you use a Non-PPO physician or other healthcare professional, you generally pay any difference between our allowance and the billed amount, in addition to any share of our allowance shown below.
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; 15%* of our allowance; $25 per office visit for primary care physicians and other healthcare professionals
$35 per office visit for specialists
Non-PPO: 35%* of our allowance
39-46
Medical services provided by physicians: Telehealth services
PPO: Nothing for the first 2 visits per calendar year after the 2nd visit: $10 copayment per visit
Non-PPO: You pay all charges
39, 99
Services provided by a hospital: Inpatient
PPO: $350 per admission
Non-PPO: $450 per admission, plus 35% of our allowance
79-81
Services provided by a hospital: Outpatient
PPO: 15%* of our allowance
Non-PPO: 35%* of our allowance
81-85
Emergency benefits: Accidental injury
PPO: Nothing for outpatient hospital and physician services within 72 hours; regular benefits thereafter
Non-PPO: Any difference between the Plan allowance and billed amount for outpatient hospital and physician services within 72 hours; regular benefits thereafter
Ambulance transport services: Nothing
95-96
Emergency benefits: Medical emergency
PPO urgent care: $30 copayment; PPO and Non-PPO emergency room care: 15%* of our allowance; Regular benefits for physician and hospital care* provided in other than the emergency room/PPO urgent care center
Ambulance transport services: $100 per day for ground ambulance (no deductible); $150 per day for air or sea ambulance (no deductible)
96-97
Mental health and substance use disorder treatment
PPO: Regular cost-sharing, such as $25 office visit copay; $350 per inpatient admission
Non-PPO: Regular cost-sharing, such as 35%* of our allowance for office visits; $450 per inpatient admission to Member facilities, plus 35% of our allowance
98-102
Prescription drugs
Retail Pharmacy Program:
Dental care
Scheduled allowances for diagnostic and preventive services; regular benefits for dental services required due to accidental injury and covered oral and maxillofacial surgery
123
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; 15%* of our allowance; $25 per office visit for primary care physicians and other healthcare professionals
$35 per office visit for specialists
Non-PPO: 35%* of our allowance
39-46
Medical services provided by physicians: Telehealth services
PPO: Nothing for the first 2 visits per calendar year after the 2nd visit: $10 copayment per visit
Non-PPO: You pay all charges
39, 99
Services provided by a hospital: Inpatient
PPO: $350 per admission
Non-PPO: $450 per admission, plus 35% of our allowance
79-81
Services provided by a hospital: Outpatient
PPO: 15%* of our allowance
Non-PPO: 35%* of our allowance
81-85
Emergency benefits: Accidental injury
PPO: Nothing for outpatient hospital and physician services within 72 hours; regular benefits thereafter
Non-PPO: Any difference between the Plan allowance and billed amount for outpatient hospital and physician services within 72 hours; regular benefits thereafter
Ambulance transport services: Nothing
95-96
Emergency benefits: Medical emergency
PPO urgent care: $30 copayment; PPO and Non-PPO emergency room care: 15%* of our allowance; Regular benefits for physician and hospital care* provided in other than the emergency room/PPO urgent care center
Ambulance transport services: $100 per day for ground ambulance (no deductible); $150 per day for air or sea ambulance (no deductible)
96-97
Mental health and substance use disorder treatment
PPO: Regular cost-sharing, such as $25 office visit copay; $350 per inpatient admission
Non-PPO: Regular cost-sharing, such as 35%* of our allowance for office visits; $450 per inpatient admission to Member facilities, plus 35% of our allowance
98-102
Prescription drugs
Retail Pharmacy Program:
- PPO: $7.50 for each purchase of up to a 30-day supply generic ($5.00 for a 30-day supply if you have Medicare Part B primary)/30% of our allowance Preferred brand-name/50% of our allowance non-preferred brand-name
- Non-PPO: 45% of our allowance (AWP)
- $15 generic ($10 if you have Medicare Part B primary)/$90 Preferred brand-name/$125 non-preferred brand-name per prescription; up to a 90-day supply
- $65 preferred specialty drug for a purchase of up to a 30-day supply; $85 non-preferred specialty drug for a purchase of up to a 30-day supply
Dental care
Scheduled allowances for diagnostic and preventive services; regular benefits for dental services required due to accidental injury and covered oral and maxillofacial surgery
123
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 $6,000 (PPO) or $8,000 (PPO/Non-PPO) per contract per year
- Self Plus One: Nothing after $12,000 (PPO) or $16,000 (PPO/Non-PPO) per contract per year
- Self and Family: Nothing after $12,000 (PPO) or $16,000 (PPO/Non-PPO) per contract 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