• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the FEHB Program - 9
• Enrollment types available for you and your family - 9
• Family member coverage - 10
• Children’s Equity Act - 10
• When benefits and premiums start - 11
• When you retire - 11

When you lose benefits - 12

• When FEHB coverage ends - 12
• Upon divorce - 12
• Temporary Continuation of Coverage (TCC) - 12
• Finding replacement coverage - 12
• Health Insurance Marketplace - 13

Section 1. How This Plan Works - 14

General features of FEP Blue Focus - 14
We have a Preferred Provider Organization (PPO) - 14
How we pay professional and facility providers - 14
Your rights and responsibilities - 15
Your medical and claims records are confidential - 15

Section 2. Changes for 2025 - 16
Section 3. How You Get Care - 17

Identification cards - 17
Where you get covered care - 17
Balance Billing Protection - 17

• Covered professional providers - 17
• Covered facility providers - 17

What you must do to get covered care - 19

• Transitional care - 19
• If you are hospitalized when your enrollment begins - 19

You need prior Plan approval for certain services - 20

• Inpatient hospital admission, inpatient residential treatment center admission - 20
• Other services - 20
• Special prior authorization situations related to coordination of benefits (COB) - 23
• Prior notification – Maternity care - 25

How to request precertification for an admission or get prior approval for Other services - 25

• Non-urgent care claims - 25
• Urgent care claims - 26
• Concurrent care claims - 26
• Emergency inpatient admission - 26
• Maternity care - 27
• If your facility stay needs to be extended - 27
• If your treatment needs to be extended - 27

If you disagree with our pre-service claim decision - 27

• To reconsider a non-urgent care claim - 27
• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 28

Section 4. Your Costs for Covered Services - 29

Cost-share/Cost-sharing - 29
Copayment - 29
Deductible - 29
Coinsurance - 29
If your provider routinely waives your cost - 29
Waivers - 30
Differences between our allowance and the bill - 30
Important Notice About Surprise Billing – Know Your Rights - 30
Your costs for other care - 31
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 31
Carryover - 32
If we overpay you - 32
When Government facilities bill us - 32
The Federal Flexible Spending Account Program - FSAFEDS - 32

Section 5. FEP Blue Focus Benefits - 33

Section 5. FEP Blue Focus Overview - 35
Non-FEHB Benefits Available to Plan Members - 110

Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 111
Section 7. Filing a Claim for Covered Services - 113
Section 8. The Disputed Claims Process - 116
Section 9. Coordinating Benefits With Medicare and Other Coverage - 119

When you have other health coverage - 119

• TRICARE and CHAMPVA - 119
• Workers’ Compensation - 120
• Medicaid - 120

When other Government agencies are responsible for your care - 120
When others are responsible for injuries - 120
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 121
Clinical trials - 122
When you have Medicare - 122

• The Original Medicare Plan (Part A or Part B) - 122
• Tell us about your Medicare coverage - 123
• Private contract with your physician - 123
• Medicare Advantage (Part C) - 123
• Medicare prescription drug coverage (Part D) - 124
• Medicare prescription drug coverage (Part B) - 124

When you are age 65 or over and do not have Medicare - 126 , , , , ,
Physicians Who Opt-Out of Medicare - 127
When you have the Original Medicare Plan (Part A, Part B, or both) - 127

Section 10. Definitions of Terms We Use in This Brochure - 129
Index - 138
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2025 - 140
2025 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan - 146