Blue Cross and Blue Shield Service Benefit Plan Brochure - 2026

PSHB Standard and Basic Options

 

Document list

Document Name Document Number
Cover page PSB26.00.1.1
Inside cover PSB26.00.1.2
Table of Contents PSB26.00.1.3
Introduction PSB26.00.2.1
Plain Language PSB26.00.2.2
Stop Healthcare Fraud! PSB26.00.2.3
Discrimination is Against the Law PSB26.00.2.4
Preventing Medical Mistakes PSB26.00.2.5
No pre-existing condition limitation PSB26.00.3.1.1
Minimum essential coverage (MEC) PSB26.00.3.1.2
Minimum value standard PSB26.00.3.1.3
Where you can get information about enrolling in the PSHB Program PSB26.00.3.1.4
Enrollment types available for you and your family PSB26.00.3.1.5
Family member coverage PSB26.00.3.1.6
Children's Equity Act PSB26.00.3.1.7
Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) PSB26.00.3.1.7.1
When benefits and premiums start PSB26.00.3.1.8
When you retire PSB26.00.3.1.9
When PSHB coverage ends PSB26.00.3.2.1
Upon divorce PSB26.00.3.2.2
Medicare PDP EGWP PSB26.00.3.2.2.1
Temporary Continuation of Coverage (TCC) PSB26.00.3.2.3
Finding replacement coverage PSB26.00.3.2.4
Health Insurance Marketplace PSB26.00.3.2.5
Section 1. How This Plan Works PSB26.01.0
General features of our Standard and Basic Options//We have a Preferred Provider Organization (PPO) PSB26.01.1
How we pay professional and facility providers PSB26.01.2
Your rights and responsibilities PSB26.01.3
Your medical and claims records are confidential PSB26.01.4
Section 2. Changes for 2026 PSB26.02.0
Identification cards PSB26.03.1
Where you get covered care PSB26.03.2.0
Balance Billing Protection PSB26.03.2.05
Covered professional providers PSB26.03.2.1
Covered facility providers PSB26.03.2.2
What you must do to get covered care PSB26.03.3.0
Transitional care PSB26.03.3.1
If you are hospitalized when your enrollment begins PSB26.03.3.2
You need prior Plan Approval for certain services PSB26.03.4.00
Inpatient hospital, residential treatment center, or skilled nursing facility admission PSB26.03.4.01
Other services PSB26.03.4.02
Surgery by Non-participating providers under Standard Option PSB26.03.4.03
How to request precertification for an admission or get approval for Other services PSB26.03.4.04
Non-urgent care claims PSB26.03.4.05
Urgent care claims PSB26.03.4.06
Concurrent care claims PSB26.03.4.07
Emergency inpatient admission PSB26.03.4.08
Maternity care PSB26.03.4.09
If your facility stay needs to be extended PSB26.03.4.10
If your treatment needs to be extended PSB26.03.4.11
If you disagree with our pre-service claim decision PSB26.03.5.0
To reconsider a non-urgent care claim PSB26.03.5.1
To reconsider an urgent care claim PSB26.03.5.2
To file an appeal with OPM PSB26.03.5.3
Cost share/Cost-sharing PSB26.04.01
Copayment PSB26.04.02
Deductible PSB26.04.03
Coinsurance PSB26.04.04
If your provider routinely waives your cost PSB26.04.05
Waivers PSB26.04.06
Differences between our allowance and the bill PSB26.04.07
Important Notice About Surprise Billing — Know Your Rights PSB26.04.08
Your costs for other care PSB26.04.09
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments PSB26.04.10
Carryover PSB26.04.11
If we overpay you PSB26.04.12
When Government facilities bill us PSB26.04.13
Section 5. Benefits [Table of Contents] PSB26.05.01
Section 5. Standard and Basic Option Overview PSB26.05.02
Section 5(a). Overview PSB26.05a.0
Diagnostic and Treatment Services PSB26.05a.01
Lab, X-ray and Other Diagnostic Tests PSB26.05a.02
Preventive Care, Adult PSB26.05a.03
Preventive Care, Child PSB26.05a.04
Maternity Care PSB26.05a.05
Family Planning PSB26.05a.06
Reproductive Services PSB26.05a.07
Allergy Care PSB26.05a.08
Treatment Therapies PSB26.05a.09
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy PSB26.05a.10
Hearing Services (Testing, Treatment, and Supplies) PSB26.05a.11
Vision Services (Testing, Treatment, and Supplies) PSB26.05a.12
Foot Care PSB26.05a.13
Orthopedic and Prosthetic Devices PSB26.05a.14
Durable Medical Equipment (DME) PSB26.05a.15
Medical Supplies PSB26.05a.16
Home Health Services PSB26.05a.17
Manipulative Treatment PSB26.05a.18
Alternative Treatments PSB26.05a.19
Educational Classes and Programs PSB26.05a.20
Section 5(b). Overview PSB26.05b.0
Surgical Procedures PSB26.05b.1
Reconstructive Surgery PSB26.05b.2
Oral and Maxillofacial Surgery PSB26.05b.3
Organ/Tissue Transplants PSB26.05b.4
Anesthesia PSB26.05b.5
Section 5(c). Overview PSB26.05c.0
Inpatient Hospital PSB26.05c.1
Outpatient Hospital or Ambulatory Surgical Center PSB26.05c.2
Blue Distinction Specialty Care PSB26.05c.3
Residential Treatment Center PSB26.05c.4
Extended Care Benefits/Skilled Nursing Care Facility Benefits PSB26.05c.5
Hospice Care PSB26.05c.6
Ambulance PSB26.05c.7
Section 5(d). Overview PSB26.05d.0
Accidental Injury PSB26.05d.1
Medical Emergency PSB26.05d.2
Ambulance PSB26.05d.3
Section 5(e). Overview PSB26.05e.0
Professional Services PSB26.05e.1
Inpatient Hospital or Other Covered Facility PSB26.05e.2
Residential Treatment Center PSB26.05e.3
Outpatient Hospital or Other Covered Facility PSB26.05e.4
Not Covered (Inpatient or Outpatient) PSB26.05e.5
Section 5(f). Overview PSB26.05f.0
There are important features you should be aware of PSB26.05f.01
Who can write your prescriptions PSB26.05f.02
Where you can obtain them PSB26.05f.03
What is covered PSB26.05f.04
Generic equivalents PSB26.05f.05
Disclosure of information PSB26.05f.06
These are the dispensing limitations PSB26.05f.07
Patient Safety and Quality Monitoring (PSQM) PSB26.05f.08
Prior Approval PSB26.05f.09
Standard Option Generic Incentive Program PSB26.05f.10
Medical Foods PSB26.05f.11
Here is how to obtain your prescription drugs and supplies PSB26.05f.12
Preferred Retail Pharmacies PSB26.05f.13
Non-preferred Retail Pharmacies PSB26.05f.14
Mail Service Prescription Drug Program PSB26.05f.15
Specialty Drug Pharmacy Program PSB26.05f.16
Asthma Medications PSB26.05f.17
Other Preferred Diabetic Medications, Test Strips, and Supplies PSB26.05f.18
Diabetic Meter Program PSB26.05f.19
Section 5(f)(a). MPDP Overview PSB26.05f.20
MPDP There are important features you should be aware of PSB26.05f.21
MPDP Who can write your prescriptions PSB26.05f.22
MPDP Where you can obtain prescription drugs PSB26.05f.23
MPDP We use a managed formulary PSB26.05f.24
MPDP These are the dispensing limitations PSB26.05f.25
MPDP Prior Approval PSB26.05f.26
MPDP Generic equivalents PSB26.05f.27
MPDP How to obtain your prescription drugs and supplies PSB26.05f.28
MPDP Medical Foods PSB26.05f.29
MPDP When you do have to file a claim PSB26.05f.30
MPDP Disclosure of information PSB26.05f.31
MPDP Important Contact Information PSB26.05f.31.1
MPDP Catastrophic Maximums PSB26.05f.32
MPDP Retail Pharmacies PSB26.05f.33
MPDP Mail Service Prescription Drug Program PSB26.05f.34
MPDP Asthma Medications PSB26.05f.35
MPDP Other Preferred Diabetic Medications, Test Strips, and Supplies PSB26.05f.36
Smoking and Tobacco Cessation Medications PSB26.05f.37
Anti-hypertensive Medications PSB26.05f.38
Over-the-counter (OTC) contraceptive drugs and devices PSB26.05f.39
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network PSB26.05f.40
Metformin and metformin extended release (excluding osmotic and modified release generic drugs) PSB26.05f.41
Medications to promote better health as recommended under the ACA PSB26.05f.42
Generic medications to reduce breast cancer risk for women PSB26.05f.43
Bowel preparation medications and antiretroviral therapy medications for HIV PSB26.05f.44
Opioid Rescue Agents PSB26.05f.45
Not Covered PSB26.05f.46
Drugs From Other Sources PSB26.05f.47
Section 5(g). Overview PSB26.05g.0
Accidental Injury Benefit PSB26.05g.1
Dental Benefits PSB26.05g.2
Health Tools PSB26.05h.01
Services for the Deaf and Hearing Impaired PSB26.05h.02
Web Accessibility for the Visually Impaired PSB26.05h.03
Travel Benefit/Services Overseas PSB26.05h.04
Healthy Families PSB26.05h.05
Diabetes Management Program PSB26.05h.06
Blue Health Assessment PSB26.05h.07
Hypertension Management Program PSB26.05h.08
Pregnancy Care Incentive Program PSB26.05h.09
Annual Incentive Limitation PSB26.05h.10
Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B PSB26.05h.11
MyBlue Customer eService PSB26.05h.12
National Doctor & Hospital Finder PSB26.05h.13
Care Management Programs PSB26.05h.14
Flexible Benefits Option PSB26.05h.15
Telehealth Services PSB26.05h.16
The fepblue Mobile Application PSB26.05h.17
Weight Loss Management Program PSB26.05h.18
Section 5(i). Services, Drugs, and Supplies Provided Overseas PSB26.05i.0
Non-PSHB Benefits Available to Plan Members PSB26.05N.0
Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover PSB26.06
Section 7. Filing a Claim for Covered Services PSB26.07
Section 8. The Disputed Claims Process PSB26.08
Section 8(a). Medicare PDP EGWP Disputed Claims Process PSB26.08.a
When you have other health coverage PSB26.09.1.0
TRICARE and CHAMPVA PSB26.09.1.1
Workers' Compensation PSB26.09.1.2
Medicaid PSB26.09.1.3
When other Government agencies are responsible for your care PSB26.09.2
When others are responsible for injuries PSB26.09.3
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) PSB26.09.4
Clinical trials PSB26.09.5
When you have Medicare PSB26.09.6.1
The Original Medicare Plan (Part A or Part B) PSB26.09.6.2
Tell us about your Medicare coverage PSB26.09.6.3
Private contract with your physician PSB26.09.6.4
Medicare Advantage (Part C) PSB26.09.6.5
Medicare prescription drug coverage (Part D) PSB26.09.6.6
Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) PSB26.09.6.6.1
Medicare prescription drug coverage (Part B) PSB26.09.6.7
Primary payor chart PSB26.09.6.8
When you are age 65 or over and do not have Medicare PSB26.09.7
Physicians Who Opt-Out of Medicare PSB26.09.8
When you have the Original Medicare Plan (Part A, Part B, or both) PSB26.09.9
Cost-share when Medicare is your primary payor PSB26.09.95
Section 10. Definitions of Terms We Use in This Brochure PSB26.10
Index PSB26.11
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2026 PSB26.12.1
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2026 PSB26.12.2
2026 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan PSB26.13
Quick Links PSB26.QL
Cover page PSB26-000-1
Inside cover PSB26-000-2
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