2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Table of Contents
Page 2

 

• Emergency inpatient admission - 28
• Maternity care - 28
• If your facility stay needs to be extended - 28
• If your treatment needs to be extended - 28
If you disagree with our pre-service claim decision - 28
• To reconsider a non-urgent care claim - 28
• To reconsider an urgent care claim - 29
• To file an appeal with OPM - 29
Section 4. Your Costs for Covered Services - 30
Cost-share/Cost-sharing - 30
Copayment - 30
Deductible - 30
Coinsurance - 31
If your provider routinely waives your cost - 31
Waivers - 31
Differences between our allowance and the bill - 31
Important Notice About Surprise Billing — Know Your Rights - 34
Your costs for other care - 34
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 35
Carryover - 36
If we overpay you - 36
When Government facilities bill us - 36
Section 5. Benefits - 37
Non-PSHB Benefits Available to Plan Members - 137
Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover - 138
Section 7. Filing a Claim for Covered Services - 140
Section 8. The Disputed Claims Process - 144
Section 8(a). Medicare PDP EGWP Disputed Claims Process - 147
Section 9. Coordinating Benefits With Medicare and Other Coverage - 148
When you have other health coverage - 148
• TRICARE and CHAMPVA - 148
• Workers’ Compensation - 149
• Medicaid - 149
When other Government agencies are responsible for your care - 149
When others are responsible for injuries - 149
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 150
Clinical trials - 150
When you have Medicare - 151
• The Original Medicare Plan (Part A or Part B) - 151
• Tell us about your Medicare coverage - 152
• Private contract with your physician - 152
• Medicare Advantage (Part C) - 152
• Medicare prescription drug coverage (Part D) - 153
• Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) - 153
• Medicare prescription drug coverage (Part B) - 154
When you are age 65 or over and do not have Medicare - 156
Physicians Who Opt-Out of Medicare - 157
When you have the Original Medicare Plan (Part A, Part B, or both) - 157
Section 10. Definitions of Terms We Use in This Brochure - 159
Index - 169
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2026 - 171