Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus

Blue Cross

and Blue Shield

Service Benefit Plan

FEP

Blue Focus

www.fepblue.org

2022

A Fee-For-Service Plan (FEP Blue Focus) with a Preferred Provider

Organization

IMPORTANT

• Rates: Back Cover

• Changes for 2022: Page 15

• Summary of Benefits: Page 139

This Plan’s health coverage qualifies as minimum essential coverage

and meets the minimum value standard for the benefits it provides. See

page 9 for details. This Plan is accredited. See page 13.

Sponsored and administered by: The Blue Cross and Blue Shield

Association and participating Blue Cross and Blue Shield Plans

Who may enroll in this Plan: All Federal employees, Tribal

employees, and annuitants who are eligible to enroll in the Federal

Employees Health Benefits Program

Enrollment codes for this Plan:

131 FEP Blue Focus - Self Only

133 FEP Blue Focus - Self Plus One

132 FEP Blue Focus - Self and Family

RI 71-017

Important Notice from the Blue Cross and Blue Shield Service Benefit Plan About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the Blue Cross and Blue Shield Service Benefit Plan’s prescription

drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan

participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for

prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as

long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits

with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as

Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every

month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage,

your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as

long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election

Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information

regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the

SSA at 800-772-1213, TTY: 800-325-0778.

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

•Visit www.medicare.gov for personalized help.

•Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.

RI 71-017

Table of Contents

Introduction ...................................................................................................................................................................................4

Plain Language ..............................................................................................................................................................................4

Stop Healthcare Fraud! .................................................................................................................................................................4

Discrimination is Against the Law ................................................................................................................................................5

Preventing Medical Mistakes ........................................................................................................................................................6

FEHB Facts ...................................................................................................................................................................................9

Coverage information .........................................................................................................................................................9

• 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

• Types of coverage 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 .....................................................................................................................................................11

• When FEHB coverage ends ..........................................................................................................................................11

• Upon divorce ................................................................................................................................................................12

• Temporary Continuation of Coverage (TCC) ...............................................................................................................12

• Finding replacement coverage ......................................................................................................................................12

• Health Insurance Marketplace ......................................................................................................................................12

Section 1. How This Plan Works ................................................................................................................................................13

General features of FEP Blue Focus .................................................................................................................................13

We have a Preferred Provider Organization (PPO) ...........................................................................................................13

How we pay professional and facility providers ...............................................................................................................13

Your rights and responsibilities .........................................................................................................................................14

Your medical and claims records are confidential ............................................................................................................14

Section 2. Changes for 2022 .......................................................................................................................................................15

Section 3. How You Get Care .....................................................................................................................................................16

Identification cards ............................................................................................................................................................16

Where you get covered care ..............................................................................................................................................16

Balance Billing Protection ................................................................................................................................................16

• Covered professional providers ....................................................................................................................................16

• Covered facility providers ............................................................................................................................................17

What you must do to get covered care ..............................................................................................................................18

• Transitional care ...........................................................................................................................................................18

• If you are hospitalized when your enrollment begins ...................................................................................................18

You need prior Plan approval for certain services ............................................................................................................19

• Inpatient hospital admission, inpatient residential treatment center admission ...........................................................19

• Other services ...............................................................................................................................................................19

• Special prior authorization situations related to coordination of benefits (COB) ........................................................23

• Prior notification – Maternity care ...............................................................................................................................24

How to request precertification for an admission or get prior approval for Other services .............................................24

• Non-urgent care claims .................................................................................................................................................25

• Urgent care claims ........................................................................................................................................................25

• Concurrent care claims .................................................................................................................................................26

• Emergency inpatient admission ....................................................................................................................................26

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• Maternity care ...............................................................................................................................................................26

• If your facility stay needs to be extended .....................................................................................................................26

• If your treatment needs to be extended .........................................................................................................................26

If you disagree with our pre-service claim decision .........................................................................................................26

• To reconsider a non-urgent care claim ..........................................................................................................................27

• To reconsider an urgent care claim ...............................................................................................................................27

• To file an appeal with OPM ..........................................................................................................................................27

• The Federal Flexible Spending Account Program – FSAFEDS ...................................................................................27

Section 4. Your Costs for Covered Services ...............................................................................................................................28

Cost-share/Cost-sharing ....................................................................................................................................................28

Copayment ........................................................................................................................................................................28

Deductible .........................................................................................................................................................................28

Coinsurance .......................................................................................................................................................................28

If your provider routinely waives your cost ......................................................................................................................28

Waivers ..............................................................................................................................................................................29

Differences between our allowance and the bill ...............................................................................................................29

Important Notice About Surprise Billing – Know Your Rights ........................................................................................29

Your costs for other care ...................................................................................................................................................30

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments ...........................30

Carryover ..........................................................................................................................................................................30

If we overpay you .............................................................................................................................................................31

When Government facilities bill us ..................................................................................................................................31

Section 5. FEP Blue Focus Benefits ............................................................................................................................................32

Section 5. FEP Blue Focus Overview ...............................................................................................................................34

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 ...................................................................................................................................................................121

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) ...........................................................................................................123

• Medicare prescription drug coverage (Part B) ...........................................................................................................123

When you are age 65 or over and do not have Medicare ................................................................................................125

Physicians Who Opt-Out of Medicare ............................................................................................................................126

When you have the Original Medicare Plan (Part A, Part B, or both) ............................................................................126

Section 10. Definitions of Terms We Use in This Brochure .....................................................................................................128

Index ..........................................................................................................................................................................................137

Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2022 ...............................139

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2022 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan ....................................................................142

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Introduction

This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan – FEP Blue Focus under contract (CS

1039) between the Blue Cross and Blue Shield Association and the United States Office of Personnel Management, as authorized by

the Federal Employees Health Benefits law. This Plan is underwritten by participating Blue Cross and Blue Shield Plans (Local Plans)

that administer this Plan in their individual localities. For customer service assistance, visit our website, www.fepblue.org, or contact

your Local Plan at the phone number appearing on the back of your FEP Blue Focus ID card.

The address for the Blue Cross and Blue Shield Service Benefit Plan administrative office is:

Blue Cross and Blue Shield Service Benefit Plan

1310 G Street NW, Suite 900

Washington, DC 20005

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and

exclusions of this brochure. It is your responsibility to be informed about your healthcare benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self

and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were

available before January 1, 2022, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefits are effective January 1, 2022, and are summarized on page 15.

Rates are shown on the back cover of this brochure.

Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:

•Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family

member; “we” means the Blue Cross and Blue Shield Service Benefit Plan.

•We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office

of Personnel Management. If we use others, we tell you what they mean.

•Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.

Stop Healthcare Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the

agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things you can do to prevent fraud:

•Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare provider,

authorized health benefits plan, or OPM representative.

•Let only the appropriate medical professionals review your medical record or recommend services.

•Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

•Carefully review explanations of benefits (EOBs) statements that you receive from us.

•Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.

•Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.

•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or

misrepresented any information, do the following:

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- Call the provider and ask for an explanation. There may be an error.

- If the provider does not resolve the matter, call the FEP Fraud Hotline at 800-FEP-8440 (800-337-8440) and explain the

situation.

- If we do not resolve the issue:

CALL – THE HEALTHCARE FRAUD HOTLINE

877-499-7295

OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form

The online form is the desired method of reporting fraud in order to ensure accuracy, and a quick response time.

You can also write to:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC 20415-1100

•Do not maintain as a family member on your policy:

- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or

- Your child age 26 or over (unless they were disabled and incapable of self-support prior to age 26).

- A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s

FEHB enrollment.

•If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your

retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary

Continuation of Coverage (TCC).

•Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your

agency may take action against you. Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining

service or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when you are no longer

eligible.

•If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and

premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be

billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for

which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your

health insurance coverage.

Discrimination is Against the Law

The Blue Cross and Blue Shield Service Benefit Plan complies with all applicable Federal civil rights laws, including Title VII of the

Civil Rights Act of 1964.

We:

•Provide free aids and services to people with disabilities to communicate effectively with us, such as:

- Qualified sign language interpreters

- Written information in other formats (large print, audio, accessible electronic formats, other formats)

•Provide free language services to people whose primary language is not English, such as:

- Qualified interpreters

- Information written in other languages

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If you need these services, contact the Civil Rights Coordinator of your Local Plan by contacting your Local Plan at the phone number

appearing on the back of your ID card.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin,

age, disability, or sex, you can file a grievance with the Civil Rights Coordinator of your Local Plan. You can file a grievance in

person or by mail, fax, or email. If you need help filing a grievance, your Local Plan’s Civil Rights Coordinator is available to help

you.

Members may file a complaint with the HHS Office of Civil Rights, OPM, or FEHB Program Carriers.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:

Office of Personnel Management

Healthcare and Insurance

Federal Employee Insurance Operations

Attention: Assistant Director, FEIO

1900 E Street NW, Suite 3400-S

Washington, D.C. 20415-3610

For further information about how to file a civil rights complaint, go to www.fepblue.org/en/rights-and-responsibilities/, or call the

customer service phone number on the back of your ID card. For TTY, dial 711.

Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic

outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and

additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and

healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies.

You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and

understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

•Ask questions and make sure you understand the answers.

•Choose a doctor with whom you feel comfortable talking.

•Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

•Bring the actual medications or give your doctor and pharmacist a list of all the medications and dosages that you take, including

non-prescription (over-the-counter) medications and nutritional supplements.

•Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.

•Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or

pharmacist says.

•Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you

expected.

•Read the label and patient package insert when you get your medication, including all warnings and instructions.

•Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.

•Contact your doctor or pharmacist if you have any questions.

•Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking

both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

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3. Get the results of any test or procedure.

•Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or

Provider’s portal?

•Do not assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.

•Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

•Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or

clinic to choose from to get the healthcare you need.

•Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

•Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.

•Ask your doctor, “Who will manage my care when I am in the hospital?”

•Ask your surgeon:

- “Exactly what will you be doing?”

- “About how long will it take?”

- “What will happen after surgery?”

- “How can I expect to feel during recovery?”

•Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional

supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

•www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps healthcare organizations to improve the quality

and safety of the care they deliver.

•www.ahrq.gov/patients-consumers. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics

not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care

you receive.

•www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about

the safe, appropriate use of medications.

•www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.

•www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve

patient safety.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or

other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable,

patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions.

Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients can indicate a significant

problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called “Never Events” or

“Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain

infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither

you nor your FEHB plan will incur costs to correct the medical error.

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You will not be billed for inpatient services when care is related to treatment of specific hospital-acquired conditions if you use

Preferred hospitals. This policy helps to protect you from having to pay for the cost of treating these conditions, and it encourages

hospitals to improve the quality of care they provide.

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FEHB Facts

Coverage information

We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan

solely because you had the condition before you enrolled.

• No pre-existing

condition limitation

Coverage under this Plan qualifies as minimum essential coverage. Please visit the Internal Revenue

Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-

Responsibility-Provision for more information on the individual requirement for MEC.

• Minimum essential

coverage (MEC)

Our health coverage meets the minimum value standard of 60% established by the ACA. This means

that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits.

The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained

in this brochure.

• Minimum value

standard

See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:

• Information on the FEHB Program and plans available to you

• A health plan comparison tool

• A list of agencies that participate in Employee Express

• A link to Employee Express

• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions and give you brochures for

other plans and other materials you need to make an informed decision about your FEHB coverage.

These materials tell you:

• When you may change your enrollment

• How you can cover your family members

• What happens when you transfer to another Federal agency, go on leave without pay, enter

military service, or retire

• What happens when your enrollment ends

• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment

status without information from your employing or retirement office. For information on your

premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for updates and

questions about your benefit coverage.

• Where you can get

information about

enrolling in the

FEHB Program

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one

eligible family member. Self and Family coverage is for the enrollee and one or more eligible family

members. Family members include your spouse and your dependent children under age 26, including

any foster children authorized for coverage by your employing agency or retirement office. Under

certain circumstances, you may also continue coverage for a disabled child 26 years of age or older

who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family

enrollment if you marry, give birth, or add a child to your family. You may change your enrollment

31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins

on the first day of the pay period in which the child is born or becomes an eligible family member.

• Types of coverage

available for you

and your family

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FEHB Facts

When you change to Self Plus One or Self and Family because you marry, the change is effective on

the first day of the pay period that begins after your employing office receives your enrollment form.

Benefits will not be available until you are married. A carrier may request that an enrollee verify the

eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent

when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self

and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible

to receive health benefits, nor will we. Please tell us immediately of changes in family member

status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan you or they cannot be

enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) – such as marriage, divorce, or the birth of a child – outside

of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change

your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.

opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing

agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your

spouse by valid common-law marriage if you reside in a state that recognizes common-law

marriages) and children as described below. A Self Plus One enrollment covers you and your spouse,

or one other eligible family member as described below.

Natural children, adopted children, and stepchildren

Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children

Coverage: Foster children are eligible for coverage until their 26th birthday if you provide

documentation of your regular and substantial support of the child and sign a certification stating that

your foster child meets all the requirements. Contact your human resources office or retirement

system for additional information.

Children incapable of self-support

Coverage: Children who are incapable of self-support because of a mental or physical disability that

began before age 26 are eligible to continue coverage. Contact your human resources office or

retirement system for additional information.

Married children

Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th

birthday.

Children with or eligible for employer-provided health insurance

Coverage: Children who are eligible for or have their own employer-provided health insurance are

covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of

the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

• Family member

coverage

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This

law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB

Program, if you are an employee subject to a court or administrative order requiring you to provide

health benefits for your child or children.

• Children’s Equity

Act

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FEHB Facts

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health

plan that provides full benefits in the area where your children live or provide documentation to your

employing office that you have obtained other health benefits coverage for your children. If you do

not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self

and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by

OPM.

• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area

where your children live, your employing office will change your enrollment to Self Plus One or

Self and Family, as appropriate, in the same option of the same plan; or

• If you are enrolled in an HMO that does not serve the area where the children live, your

employing office will change your enrollment to Self Plus One or Self and Family, as

appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the

order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to

Self Only, or change to a plan that does not serve the area in which your children live, unless you

provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still

eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and

cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in

which your children live as long as the court/administrative order is in effect. Similarly, you cannot

change to Self Plus One if the court/administrative order identifies more than one child. Contact your

employing office for further information.

The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season,

your coverage begins on the first day of your first pay period that starts on or after January 1. If you

changed plans or Plan options during Open Season and you receive care between January 1

and the effective date of coverage under your new plan or option, your claims will be processed

according to the 2022 benefits of your prior plan or option. If you have met (or pay cost-sharing

that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not

pay cost-sharing for services covered between January 1 and the effective date of coverage under

your new plan or option. However, if your prior plan left the FEHB Program at the end of the year,

you are covered under that plan’s 2021 benefits until the effective date of your coverage with your

new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time

during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated

from Federal service), and premiums are not paid, you will be responsible for all benefits paid during

the period in which premiums were not paid. You may be billed for services received directly from

your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for

which you have not paid premiums. It is your responsibility to know when you or family members

are no longer eligible to use your health insurance coverage.

• When benefits and

premiums start

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled

in the FEHB Program for the last five years of your Federal service. If you do not meet this

requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of

Coverage (TCC).

• When you retire

When you lose benefits

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or

• You are a family member no longer eligible for coverage.

• When FEHB

coverage ends

11 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEHB Facts

Any person covered under the 31-day extension of coverage who is confined in a hospital or other

institution for care or treatment on the 31st day of the temporary extension is entitled to continuation

of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day

after the end of the 31-day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy

(non-FEHB individual policy). FEP helps members with Temporary Continuation of Coverage

(TCC) and with finding replacement coverage.

If you are divorced from a Federal employee or annuitant you may not continue to get benefits under

your former spouse’s enrollment. This is the case even when the court has ordered your former

spouse to provide health benefits coverage for you. However, you may be eligible for your own

FEHB coverage under either the spouse equity law or TCC. If you are recently divorced or are

anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional

information about your coverage choices. You can also visit OPM’s website, www.opm.gov/

healthcare-insurance/healthcare/plan-information/guides. A carrier may request that an enrollee

verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB

enrollment.

• Upon divorce

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer

qualify as a family member, you may be eligible for TCC. The Affordable Care Act (ACA) did not

eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to

continue your FEHB enrollment after you retire, if you lose your Federal job, if you are a covered

dependent child and you turn age 26, regardless of marital status, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement

office or from www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. It explains

what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on

your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums.

Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-

pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage

under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan,

as long as you apply within 30 days of losing FEHB coverage.

We also want to inform you that the Patient Protection and ACA did not eliminate TCC or change the

TCC rules.

• Temporary

Continuation of

Coverage (TCC)

If you would like to purchase health insurance through the Affordable Care Act’s Health Insurance

Marketplace, please refer to the next Section of this brochure. We will help you find replacement

coverage inside or outside the Marketplace. For assistance, please contact your Local Plan at the

phone number appearing on the back of your ID card, or visit www.bcbs.com to access the website

of your Local Plan.

Note: We do not determine who is eligible to purchase health benefits coverage inside the Affordable

Care Act’s Health Insurance Marketplace. These rules are established by the Federal Government

agencies that have responsibility for implementing the Affordable Care Act and by the Marketplace.

• Finding replacement

coverage

If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace,

please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and

Human Services that provides up-to-date information on the Marketplace.

• Health Insurance

Marketplace

12 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEHB Facts

Section 1. How This Plan Works

This Plan is a fee-for-service (FFS) plan that offers covered services through Preferred providers. You can choose your own

physicians, hospitals, and other healthcare providers within our Preferred Provider Organization (PPO) network. We reimburse you or

your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered

services, and the amount we allow, may be different from other plans. Read brochures carefully.

OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized

standards. The local Plans and vendors that support Blue Cross and Blue Shield Service Benefit Plan hold accreditation from National

Committee for Quality Assurance (NCQA) and/or URAC. To learn more about this Plan’s accreditations, please visit the following

websites:

•National Committee for Quality Assurance (www.ncqa.org);

•URAC (www.URAC.org).

General features of FEP Blue Focus

We have a Preferred Provider Organization (PPO)

Our fee-for-service Plan offers services through a PPO. This means that certain hospitals and other healthcare providers are “Preferred

providers.” Your Local Plan (or, for Preferred retail pharmacies, CVS Caremark) is solely responsible for the selection of PPO

providers in your area. Contact your Local Plan for the names of PPO (Preferred) providers and to verify their continued participation.

You can also visit www.fepblue.org/provider/ to use our National Doctor & Hospital Finder

. You can reach our website through

the FEHB website, www.opm.gov/healthcare-insurance.

You must use Preferred providers in order to receive benefits. See page 18 for the exceptions to this requirement.

How we pay professional and facility providers

We pay benefits when we receive a claim for covered services. Each Local Plan contracts with hospitals and other healthcare

facilities, physicians, and other healthcare professionals in its service area, and is responsible for processing and paying claims for

services you receive within that area. Many, but not all, of these contracted providers are in our PPO (Preferred) network.

•PPO providers. PPO (Preferred) providers have agreed to accept a specific negotiated amount as payment in full for covered

services provided to you. We refer to PPO facility and professional providers as “Preferred.” They will generally bill the Local

Plan directly, who will then pay them directly. You do not file a claim. When you use Preferred providers your out-of-pocket costs

are limited to your copayment, deductible, and/or coinsurance. See Section 3 (page 18) and 5(d)

Emergency Services/Accidents

for

the exceptions to this requirement.

In Local Plan areas, Preferred providers who contract with us will accept 100% of the Plan allowance as payment in full for

covered services. As a result, you are only responsible for applicable deductible, coinsurance or copayments for covered services,

and any charges for noncovered services.

•Non-preferred providers. This is a PPO-only contract. There are no benefits for care performed by Non-preferred providers

(Participating/Non-participating) or Non-preferred facilities (Member/Non-member). You must use Preferred providers in order to

receive benefits. See page 18 for the exceptions to this requirement.

•Pilot Programs. We may implement pilot programs in one or more Local Plan areas and overseas to test the feasibility and

examine the impact of various initiatives. The pilot programs do not affect all Plan areas. Information on specific pilots is not

published in this brochure; it is communicated to members and network providers in accordance with our agreement with OPM.

Certain pilot programs may incorporate benefits that are different from those described in this brochure.

13 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 1

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our

networks, and our providers. OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make

available to you. Some of the required information is listed below.

•Years in existence

•Profit status

•Care management, including case management and disease management programs

•How we determine if procedures are experimental or investigational

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can

view the complete list of these rights and responsibilities by visiting our website, at www.fepblue.org/en/rights-and-responsibilities.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our

website at www.fepblue.org/en/terms-and-privacy/notice-of-privacy-practices to obtain our Notice of Privacy Practices. You can also

If you want more information about us, call or write to us. Our phone number is shown on the back of your ID card. You may also

visit our website at www.fepblue.org.

Your medical and claims records are confidential

We will keep your medical and claims information confidential.

Note: As part of our administration of this contract, we may disclose your medical and claims information (including your prescription

drug utilization) to any treating physicians or dispensing pharmacies. You may view our Notice of Privacy Practice for more

information about how we may use and disclose member information by visiting our website at www.fepblue.org.

14 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 1

Section 2. Changes for 2022

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 (Benefits).

Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not

change benefits.

Changes to our FEP Blue Focus

•You are no longer responsible for the difference between our allowance and a Non-participating provider’s billed charges in certain

situations described under the No Surprises ACT (NSA) federal legislation. Previously, you were responsible for these differences.

(See page 29.)

•For Self Only contracts, your catastrophic out-of-pocket maximum is now $8,500. For Self Plus One and Self and Family contracts,

your catastrophic out-of-pocket maximum is now $17,000. Previously, the out-of-pocket maximum for Self Only contracts was

$7,500; for Self Plus One and Self and Family contracts, the out-of-pocket maximum was $15,000. (See pages 30 and 34.)

•We now provide only medical benefits for EKGs. Previously, one EKG per calendar year was covered under the preventive care

adult benefit with no member cost-share.

•We now cover group counseling on prevention and reducing health risks, and group nutritional counseling under the preventive

benefit. Previously, only individual counseling was covered. (See pages 41, 44 and 55.)

•Under our maternity benefit, we now offer a breast pump and milk storage bags for members who are pregnant and/or nursing when

ordered through our fulfillment vendor. Previously, these items were covered when ordered through CVS Caremark. (See page 46.)

•We now cover nipple reconstruction after a mastectomy for female to male gender reassignment surgery. Previously, there was no

benefit for this procedure. (See page 60.)

•We no longer offer pancreas transplants as part of the Blue Distinction Centers for Transplants® Program. (See pages 62 and 66.)

•We now provide coverage for tubeless insulin delivery systems under the Tier 2 pharmacy benefit. Previously, all types of insulin

delivery systems were covered only under the durable medical equipment benefit. (See pages 94 and 97.)

•For inpatient stays at Non-member facilities resulting from medical emergencies or accidental injuries, or for emergency deliveries,

our allowance is now the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with

federal laws and regulations. Previously, our allowance for these services was the billed amount. (See page 132.)

•For outpatient services resulting from a medical emergency or accidental injury and billed by a Non-member facility, our allowance

is now the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and

regulations. Previously, our allowance for these services was the billed amount. (See page 132.)

•For non-emergency medical services performed in Preferred hospitals provided by physicians and other covered healthcare

professionals identified under the NSA that do not contract with your local Blue Cross and Blue Shield Plans and cannot balance

bill you under this regulation, our allowance is now equal to the lesser of the billed amount or the qualifying payment amount

(QPA). Previously, our allowance was equal to the greater of the Medicare participating fee schedule amount or 100% of the local

Plan allowance. (See page 133.)

•For emergency medical and mental health and substance use disorders services performed in the emergency department of a

hospital provided by physicians and other covered healthcare professionals that do not contract with your local Blue Cross and Blue

Shield Plan, our allowance is equal to the lesser of the billed amount or the qualifying payment amount (QPA) determined in

accordance with federal laws and regulations. Previously, the Plan allowance was equal to the greatest of (1) the Medicare

participating fee schedule amount or the Medicare Part B Drug Average Sale Price (ASP) for the service, drug, or supply in the

geographic area in which it was performed or obtained; or (2) 100% of the Local Plan Allowance for the service or supply in the

geographic area in which it was performed or obtained; or (3) an allowance based on equivalent Preferred provider services that is

calculated in compliance with the Affordable Care Act. (See page 133.)

•We no longer limit the difference between the Non-participating Provider Allowance (NPA) and the amount billed to $5,000 when

care is received in a Preferred facility from certain non-participating professional providers. Federal regulations now limit what you

can be billed in these situations. (See pages 29 and 133.)

15 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 2

Section 3. How You Get Care

We will send you an identification (ID) card when you enroll. You should carry your ID card with

you at all times. You will need it whenever you receive services from a covered provider, or fill a

prescription through a Preferred retail pharmacy. Until you receive your ID card, use your copy of

the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter

(for annuitants), or your electronic enrollment system (such as Employee Express) confirmation

letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if

you need replacement cards, call the Local Plan serving the area where you reside and ask them to

assist you, or write to us directly at: FEP

Enrollment Services, 840 First Street NE, Washington,

DC 20065. You may also request replacement cards through our website, www.fepblue.org.

Identification cards

You must use those “covered professional providers” or “covered facility providers” that are

Preferred providers for FEP Blue Focus in order to receive benefits. Benefits are not available for

care from Non-preferred providers, except in very limited situations. Please refer to page 18 for the

exceptions to this requirement. Refer to page 13 for more information about Preferred providers.

You can also get care for the treatment of minor acute conditions (see page 131 for definition),

dermatology care (see page 39), and counseling for behavioral health and substance use disorder

(see page 86), and nutritional counseling (see pages 41 and 44), using teleconsultation services

delivered via phone by calling 855-636-1579, TTY: 855-636-1578, or via secure online video/

messaging at www.fepblue.org/telehealth.

Where you get covered

care

FEHB Carriers must have clauses in their in-network (participating) providers agreements. These

clauses provide that, for a service that is a covered benefit in the plan brochure or in some cases for

services determined not medically necessary, the in-network provider agrees to hold the covered

individual harmless (and may not bill) for the difference between the billed charge and the in

network contracted amount. If an in-network provider bills you for covered services over your

normal cost share (deductible, copay, coinsurance) contact your Carrier to enforce the terms of its

provider contract.

Balance Billing

Protection

We provide benefits for the services of covered professional providers, as required by Section 2706

(a) of the Public Health Service Act. Covered professional providers within the United States,

Puerto Rico, and the U.S. Virgin Islands are healthcare providers who perform covered services

when acting within the scope of their license or certification under applicable state law and who

furnish, bill, or are paid for their healthcare services in the normal course of business. Covered

services must be provided in the state in which the provider is licensed or certified. If the state has

no applicable licensing or certification requirement, the provider must meet the requirements

of the Local Plan. Your Local Plan is responsible for determining the provider’s licensing status

and scope of practice. As reflected in Section 5, the Plan does limit coverage for some services, in

accordance with accepted standards of clinical practice regardless of the geographic area.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require

healthcare delivered by healthcare providers experienced in transgender health. While gender

reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers

(benefit details found in Section 5(f)) play important roles in preventive care, you should see a

primary care provider familiar with your overall healthcare needs. Benefits described in this

brochure are available to all members meeting medical necessity guidelines.

If you have questions about covered providers or would like the names of PPO (Preferred)

providers, please contact the Local Plan where services will be performed.

• Covered professional

providers

16 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 3

Covered Preferred (PPO) facilities include those listed below, when they meet the state’s

applicable licensing or certification requirements.

Hospital – An institution, or a distinct portion of an institution, that:

1. Primarily provides diagnostic and therapeutic facilities for surgical and medical diagnoses,

treatment, and care of injured and sick persons provided or supervised by a staff of licensed

doctors of medicine (M.D.) or licensed doctors of osteopathy (D.O.), for compensation from its

patients, on an inpatient or outpatient basis;

2. Continuously provides 24-hour-a-day professional registered nursing (R.N.) services; and

3. Is not, other than incidentally, an extended care facility; a nursing home; a place for rest; an

institution for exceptional children, the aged, drug addicts, or alcoholics; or a custodial or

domiciliary institution having as its primary purpose the furnishing of food, shelter, training, or

non-medical personal services.

Note: You must use Preferred providers to receive benefits. We consider college infirmaries to be

Non-preferred (Member/Non-member) hospitals. In addition, we may, at our discretion, recognize

any institution located outside the 50 states and the District of Columbia as a Non-preferred

(Member/Non-member) hospital.

Freestanding Ambulatory Facility – A freestanding facility, such as an ambulatory surgical center,

freestanding surgicenter, freestanding dialysis center, or freestanding ambulatory medical facility,

that:

1. Provides services in an outpatient setting;

2. Contains permanent amenities and equipment primarily for the purpose of performing medical,

surgical, and/or renal dialysis procedures;

3. Provides treatment performed or supervised by doctors and/or nurses, and may include other

professional services performed at the facility; and

4. Is not, other than incidentally, an office or clinic for the private practice of a doctor or other

professional.

Note: We may, at our discretion, recognize any other similar facilities, such as birthing centers, as

freestanding ambulatory facilities.

Residential Treatment Center – Residential treatment centers (RTCs) are accredited by a

nationally recognized organization and licensed by the state, district, or territory to provide

residential treatment for medical conditions, mental health conditions, and/or substance use

disorder. Accredited healthcare facilities (excluding hospitals, skilled nursing facilities, group

homes, halfway houses, and similar types of facilities) provide 24-hour residential evaluation,

treatment and comprehensive specialized services relating to the individual’s medical, physical,

mental health, and/or substance use disorder therapy needs. RTCs offer programs for persons who

need short-term transitional services designed to achieve predicted outcomes focused on fostering

improvement or stability in functional, physical and/or mental health, recognizing the individuality,

strengths, and needs of the persons served. Benefits are available for services performed and billed

by RTCs, as described on pages 76-77 and 87. If you have questions about treatment at an RTC,

please contact us at the customer service phone number listed on the back of your ID card.

Blue Distinction

Specialty Care

Blue Distinction Specialty Care, our centers of excellence program, focuses on effective treatment

for specialty procedures, such as: Bariatric Surgery, Cardiac Care, Knee and Hip Replacement,

Spine Surgery, Transplants, Cancer Care, Cellular Immunotherapy (CAR-T), Gene Therapy,

Maternity Care, and Substance Use Treatment and Recovery. Using national evaluation criteria

developed with input from medical experts, the Blue Distinction Centers offer comprehensive care

delivered by multidisciplinary teams with subspecialty training and distinguished clinical expertise.

Providers demonstrate quality care, treatment expertise and better overall patient results.

• Covered facility

providers

17 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 3

Bariatric and Transplant care benefits are limited to services provided in a Blue Distinction Center.

For more information, including the list of transplants that must be performed at a Blue Distinction

Center see Section 5(b), pages 57 and 62.

For listings of Blue Distinction Centers, visit https://www.bcbs.com/blue-distinction-center/facility;

access our National Doctor & Hospital Finder via www.fepblue.org/provider; or call us at the

customer service phone number listed on the back of your ID card.

Other facilities specifically listed in the benefits descriptions in Section 5(c).

You must use Preferred providers in order to receive benefits, except under the situations

listed below. In addition, we must approve certain types of care in advance. Please refer to Section

Your Costs for Covered Services

, for related benefits information.

Exceptions:

1. Medical emergency or accidental injury care in a hospital emergency room and related

ambulance transport as described in Section 5(d),

Emergency Services/Accidents

;

2. Professional care provided at Preferred facilities by Non-preferred radiologists,

anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency

room physicians, and assistant surgeons;

3. Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred

laboratories, radiologists, and outpatient facilities;

4. Services of assistant surgeons;

5. Care received outside the United States, Puerto Rico, and the U.S. Virgin Islands; or

6. Special provider access situations, other than those described above. We encourage you to

contact your Local Plan for more information in these types of situations before you receive

services from a Non-preferred provider.

Unless otherwise noted in Section 5, when services are covered as an exception for Non-

preferred provider care, you are responsible for the applicable coinsurance or copayment,

and may also be responsible for any difference between our allowance and the billed amount.

What you must do to get

covered care

Specialty care: If you have a chronic or disabling condition and

• lose access to your specialist because we drop out of the Federal Employees Health Benefits

(FEHB) Program and you enroll in another FEHB plan, or

• lose access to your Preferred specialist because we terminate our contract with your specialist

for reasons other than for cause,

you may be able to continue seeing your specialist and receiving any Preferred benefits for up to 90

days after you receive notice of the change. Contact us or, if we drop out of the Program, contact

your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based

on the above circumstances, you can continue to see your specialist and your Preferred benefits will

continue until the end of your postpartum care, even if it is beyond the 90 days.

• Transitional care

We pay for covered services from the effective date of your enrollment. However, if you are in the

hospital when your enrollment in our Plan begins, call us immediately. If you have not yet received

your ID card, you can contact your Local Plan at the phone number listed in your local phone

directory. If you already have your new ID card, call us at the phone number on the back of your ID

card. If you are new to the FEHB Program, we will reimburse you for your covered services while

you are in the hospital beginning on the effective date of your coverage.

However, if you changed from another FEHB plan to us, your former plan will pay for the hospital

stay until:

• you are discharged, not merely moved to an alternative care center;

• If you are

hospitalized when

your enrollment

begins

18 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 3

• the day your benefits from your former plan run out; or

• the 92nd day after you become a member of this Plan, whichever happens first

These provisions apply only to the benefits of the hospitalized person. If your plan terminates

participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this

continuation of coverage provision does not apply. In such cases, the hospitalized family member’s

benefits under the new plan begin on the effective date of enrollment.

The pre-service claim approval processes for inpatient hospital admissions (called precertification)

and for Other services (called prior approval) are detailed in this Section. A pre-service claim is

any claim, in whole or in part, that requires approval from us before you receive medical care or

services. In other words, a pre-service claim for benefits may require precertification and prior

approval. If you do not obtain precertification or prior approval as required, there may be a

reduction or denial of benefits. Be sure to read all of the precertification and prior approval

information below and on pages 20-22. Our FEP medical policies may be found by visiting www.

fepblue.org/policies.

You need prior Plan

approval for certain

services

Precertification is the process by which – prior to your inpatient admission – we evaluate the

medical necessity of your proposed stay, the procedure(s)/service(s) to be performed, the number of

days required to treat your condition, and any applicable benefit criteria. Unless we are misled by

the information given to us, we will not change our decision on medical necessity.

In most cases, your physician or facility will take care of requesting precertification. Because you

are still responsible for ensuring that your care is precertified, you should always ask your

physician, hospital or inpatient residential treatment center whether or not they have contacted us

and provided all necessary information. You may also contact us at the phone number on the back

of your ID card to ask if we have received the request for precertification. You are also responsible

for enrolling in case management and working with your case manager if your care involves

residential treatment. For information about precertification of an emergency inpatient hospital

admission, please see page 26.

Note: Special rules apply when Medicare or another payer is primary, see pages 23-24.

• Inpatient hospital

admission, inpatient

residential treatment

center admission

We will reduce our benefits for the inpatient hospital stay by $500, even if you have obtained prior

approval for the service or procedure being performed during the stay, if no one contacts us for

precertification. If the stay is not medically necessary, we will not provide benefits for inpatient

hospital room and board or inpatient physician care; we will only pay for covered medical services

and supplies that are otherwise payable on an outpatient basis.

Note: If precertification was not obtained prior to admission, inpatient benefits (such as room and

board) are not available for inpatient care at a residential treatment center. We will pay only for

covered medical services and supplies that are otherwise payable on an outpatient basis.

Warning:

You do not need precertification in these cases:

You are admitted to a hospital outside the United States; with the exception of admissions for

gender reassignment surgery and admissions to residential treatment centers.

Note: Special rules apply when Medicare or another payer is primary, see pages 23-24.

Exceptions:

You must obtain prior approval for these services in all outpatient and inpatient settings

unless otherwise noted. Failure to obtain prior approval will result in a $100 penalty.

Precertification is also required if the service or procedure requires an inpatient hospital

admission. However, special rules apply when Medicare or another payer is primary, see

pages 23-24. If an inpatient admission is necessary, precertification is also required. Contact

us using the customer service phone number listed on the back of your ID card before

receiving these types of services, and we will request the medical evidence needed to make a

coverage determination:

• Gene Therapy and Cellular Immunotherapy, including Car-T and T-cell receptor therapy

• Other services

19 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 3

• Air Ambulance Transport (non-emergent) – Air ambulance transport related to immediate

care of a medical emergency or accidental injury does not require prior approval; see Section 5

(c), page 80, for more information.

• Applied behavior analysis (ABA) – Prior approval is required for ABA and all related

services, including assessments, evaluations, and treatments.

• Genetic testing including the following:

- BRCA screening or diagnostic testing

- Large genomic rearrangements of the BRCA1 and BRCA2 genes screening or diagnostic

testing

- Genetic testing for the diagnosis and/or management of an existing medical condition

Note: Necessary medical evidence for BRCA related genetic testing includes the results of

genetic counseling.

• Surgical services – The surgical services on the following list require prior approval and when

care is provided in an inpatient setting, precertification is required for the hospital stay.

- Procedures to treat morbid obesity (see page 57-58)

Note: Benefits for the surgical treatment of morbid obesity – performed on an inpatient or

outpatient basis – are subject to the pre-surgical requirements listed on page 58. Benefits are

only available for the surgical treatment of morbid obesity when provided at a Blue

Distinction Specialty Care Center for Bariatric (weight loss) surgery.

Note: See pages 23-24 for special situations when another payor is primary.

- Breast reduction or augmentation not related to treatment of cancer

- Gender reassignment surgery – Prior to surgical treatment of gender dysphoria, your provider

must submit a treatment plan including all surgeries planned and the estimated date each will

be performed. A new prior approval must be obtained if the treatment plan is approved and

your provider later modifies the plan.

Note: See pages 23-24 for special situations when another payor is primary.

- Surgical correction of congenital anomalies (see definition on page 129)

- Oral maxillofacial surgeries/surgery on the jaw, cheeks, lips, tongue, roof and floor of the

mouth, and related procedures

- Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the

temporomandibular joint (TMJ)

- Orthopedic procedures: hip, knee, ankle, spine, shoulder and all orthopedic procedures using

computer-assisted musculoskeletal surgical navigation

- Reconstructive surgery for conditions other than breast cancer

- Rhinoplasty

- Septoplasty

- Varicose vein treatment

• Intensity-modulated radiation therapy (IMRT) – Prior approval is required for all IMRT

services except IMRT related to the treatment of head, neck, breast, prostate or anal cancer.

Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is

required for IMRT treatment of brain cancer.

• Hospice care – Prior approval is required for home hospice, continuous home hospice, or

inpatient hospice care services. We will advise you which home hospice care agencies we have

approved. See page 78 for information about the exception to this requirement.

• Cardiac rehabilitation

• Cochlear implants

20 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 3

• Residential treatment center care for any condition

Note: See pages 23-24 for special situations when another payor is primary.

• Prosthetic devices (external), including: microprocessor controlled limb prosthesis; electronic

and externally powered prosthesis

• Pulmonary rehabilitation

• Radiology, high technology including:

- Magnetic resonance imaging (MRI)

- Computed tomography (CT) scan

- Positron emission tomography (PET) scan

Note: High technology radiology related to immediate care of a medical emergency or

accidental injury does not require prior approval.

• Specialty durable medical equipment (DME), rental or purchase, to include:

- Specialty hospital beds

- Deluxe wheelchairs, power wheelchairs and mobility devices and related supplies

• Transplants: Prior Approval is required for all transplants, except cornea and kidney. Prior

approval is required for both the procedure and if benefits require, the transplant program;

precertification is required for inpatient care.

• Blood or marrow stem cell transplants listed on pages 63-65 must be performed in a

transplant program designated as a Blue Distinction Center for Transplants. See page 17 for

more information about these types of programs.

Not every transplant program provides transplant services for every type of transplant procedure

or condition listed, or is designated or accredited for every covered transplant. Benefits are not

provided for a covered transplant procedure unless the transplant program is specifically

designated as a Blue Distinction Center for Transplants for that procedure. Before scheduling a

transplant, call your Local Plan at the customer service phone number appearing on the back of

your ID card for assistance in locating an eligible facility and requesting prior approval for

transplant services.

• Clinical trials for certain blood or marrow stem cell transplants – See pages 64-65 for the list

of conditions covered only in clinical trials.

- Contact us at the customer service phone number on the back of your ID card for information

or to request prior approval before obtaining services. We will request the medical evidence

we need to make our coverage determination.

Even though we may state benefits are available for a specific type of clinical trial, you may not

be eligible for inclusion in these trials or there may not be any trials available in a Blue

Distinction Center for Transplants to treat your condition. If your physician has recommended

you receive a transplant or that you participate in a transplant clinical trial, we encourage you to

contact the Case Management Department at your Local Plan.

Note: For the purposes of the blood or marrow stem cell clinical trial transplants covered under

this Plan, a clinical trial is a research study whose protocol has been reviewed and approved by

the Institutional Review Board (IRB) of the Blue Distinction Center for Transplants where the

procedure is to be performed.

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• Organ/tissue transplants

Benefits for certain transplants are limited to designated transplant centers or programs.

Transplants listed on page 66 must be performed in a transplant program designated as a Blue

Distinction Center for Transplants.

The organ transplants listed on page 66 are not available in a Blue Distinction Center for

Transplants and must be performed at a Preferred facility with a Medicare-Approved Transplant

Program, if one is available.

Transplants involving more than one organ must be performed in a facility that offers a

Medicare-Approved Transplant Program for each organ transplanted. Contact your local Plan

for Medicare’s approved transplant programs.

If Medicare does not offer an approved program for a certain type of organ transplant

procedure, this requirement does not apply and you may use any covered Preferred facility and

Preferred provider that performs the procedure.

obtaining services. We will request the medical evidence we need to make our coverage

determination. Our review will include whether you meet the facility and transplant program

criteria for the particular transplant.

All members (including those who have Medicare Part A or another group health insurance

policy as their primary payor) must contact us at the customer service phone number listed on

the back of their ID card before obtaining services.

• Transplant travel – If you travel to a Blue Distinction Center for Transplants, we reimburse up

to $5,000 per transplant for costs of transportation (air, rail, bus, and/or taxi) and lodging (for

you and your traveling companions) if you live 50 miles or more from the facility.

• Prescription drugs and supplies – Certain prescription drugs and supplies, including medical

foods administered orally (see pages 94 and 131), require prior approval. Contact CVS

Caremark, our Pharmacy Program administrator, at 800-624-5060, TTY: 800-624-5077, to

request prior approval, or to obtain a list of drugs and supplies that require prior approval. We

will request the information we need to make our coverage determination. You must

periodically renew prior approval for certain drugs. See page 92 for more information about our

prescription drug prior approval program, which is part of our Patient Safety and Quality

Monitoring (PSQM) program.

Notes:

- Updates are made periodically throughout the year to the list of drugs and supplies requiring

prior approval. New drugs and supplies may be added to the list and prior approval criteria

may change. Changes to the prior approval list or to prior approval criteria are not considered

benefit changes.

- Until we approve them, you must pay for these drugs in full when you purchase them – even

if you purchase them at a Preferred retail pharmacy or through our specialty drug pharmacy –

and submit the expense(s) to us on a claim form. Preferred pharmacies will not file these

claims for you.

- The Specialty Drug Pharmacy Program will not fill your prescription until you have obtained

prior approval. CVS Caremark, the program administrator, will hold your prescription for

you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be

returned to you along with a letter explaining the prior approval procedures.

22 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 3

We will reduce our benefits by $100 for medically necessary services that require prior approval, if

no one contacts us for prior approval. If the service is not medically necessary, we will not provide

benefits. This benefit reduction does not apply to prescription drugs that require prior approval, see

page 22.

Warning:

The table below provides the special situations regarding prior approval and precertification when

Medicare is the primary payor.

Service Type: Inpatient hospital admission

Primary Payor: Medicare Part A

Precertification: No

Prior Approval: Not applicable

Service Type: Medicare hospital benefits exhausted and you do not want to use your Medicare

lifetime reserve days

Primary Payor: Medicare Part A benefits not provided

Precertification: Yes

Prior Approval: Not applicable

Service Type: Gender reassignment surgery when performed during an inpatient admission

Primary Payor: Medicare Part A

Precertification: Yes

Prior Approval: Yes

Service Type: Gender reassignment surgery in an outpatient hospital or ambulatory surgical center

(ASC)

Primary Payor: Medicare Part B

Precertification: Not applicable

Prior Approval: Yes

Service Type: Morbid obesity surgery when performed during an inpatient admission

Primary Payor: Medicare Part A

Precertification: No

Prior Approval: Yes

Service Type: Morbid obesity surgery in an outpatient hospital or ambulatory surgical center

(ASC)

Primary Payor: Medicare Part B

Precertification: Not applicable

Prior Approval: Yes

Service Type: Residential treatment center admission – inpatient

Primary Payor: Medicare Part A

Precertification: Yes

Prior Approval: Not applicable

Service Type: Residential treatment center – outpatient care

Primary Payor: Medicare Part B

Precertification: Not applicable

Prior Approval: Yes

The table below provides the special situations regarding prior approval and precertification when

another healthcare insurance is the primary payor.

Service Type: Inpatient hospital admission

Primary Payor: Other healthcare insurance

Precertification: No

Prior Approval: Not applicable

• Special prior

authorization

situations related to

coordination of

benefits (COB)

23 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 3

Service Type: Gender reassignment surgery when performed during an inpatient admission

Primary Payor: Other healthcare insurance

Precertification: Yes

Prior Approval: Yes

Service Type: Gender reassignment surgery in an outpatient hospital or ambulatory surgical center

(ASC)

Primary Payor: Other healthcare insurance

Precertification: Not applicable

Prior Approval: Yes

Service Type: Morbid obesity surgery when performed during an inpatient admission

Primary Payor: Other healthcare insurance

Precertification: No

Prior Approval: Yes

Service Type: Morbid obesity surgery in an outpatient hospital or ambulatory surgical center

(ASC)

Primary Payor: Other healthcare insurance

Precertification: Not applicable

Prior Approval: Yes

Service Type: Residential treatment center admission – inpatient

Primary Payor: Other healthcare insurance

Precertification: Yes

Prior Approval: Not applicable

Service Type: Residential treatment center – outpatient care

Primary Payor: Other healthcare insurance

Precertification: Not applicable

Prior Approval: Yes

We encourage you to notify us of your pregnancy during the first trimester. Please contact us at the

phone number on the back of your ID card and provide the following information:

• Enrollee’s name and Plan identification number

• Expected delivery date

• Date of your first prenatal appointment

• Name and phone number of the provider (i.e., physician, nurse practitioner, nurse midwife)

providing your prenatal, delivery, and postnatal care

• Name and location of the place you intend to deliver (i.e., hospital, birthing center, your home)

• If you plan to deliver in a hospital, the type of delivery and the estimated number of days you

will be in the hospital.

We will advise you if any additional information is needed.

• Prior notification –

Maternity care

You, your representative, your physician, or your hospital, residential treatment center or other

covered inpatient facility must call us at the phone number listed on the back of your ID card any

time prior to admission or before receiving services that require prior approval with the following

information:

• Enrollee’s name and Plan identification number;

• Patient’s name, birth date, and phone number;

• Reason for inpatient admission, proposed treatment, or surgery;

• Name and phone number of admitting physician;

• Name of hospital or facility;

• Number of days requested for hospital stay;

How to request

precertification for an

admission or get prior

approval for

Other

services

24 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 3

• Any other information we may request related to the services to be provided; and

• If the admission is to a residential treatment center (RTC), a preliminary treatment and

discharge plan agreed to by the member, provider and case manager at the Local Plan, and the

RTC.

Note: You must enroll and participate in case management with your Local Plan prior to,

during, and following an inpatient RTC stay. See pages 76-77 and 87 for additional information.

Note: If we approve the request for prior approval or precertification, you will be provided with a

notice that identifies the approved services and the authorization period. You must contact us with a

request for a new approval five (5) business days prior to a change to the approved original request,

and for requests for an extension beyond the approved authorization period in the notice you

received. We will advise you of the information needed to review the request for change and/or

extension.

For non-urgent care claims (including non-urgent concurrent care claims), we will tell the physician

and/or hospital the number of approved inpatient days, or the care that we approve for

Other

services

that must have prior approval. We will notify you of our decision within 15 days after the

receipt of the pre-service claim.

If matters beyond our control require an extension of time, we may take up to an additional 15 days

for review and we will notify you of the need for an extension of time before the end of the original

15-day period. Our notice will include the circumstances underlying the request for the extension

and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice

will describe the specific information required and we will allow you up to 60 days from the receipt

of the notice to provide the information.

• Non-urgent care

claims

If you have an urgent care claim (i.e., when waiting for your medical care or treatment could

seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a

physician with knowledge of your medical condition, would subject you to severe pain that cannot

be adequately managed without this care or treatment), we will expedite our review of the claim

and notify you of our decision within 72 hours as long as we receive sufficient information to

complete the review. (For concurrent care claims that are also urgent care claims, please see

If your

treatment needs to be extended

on page 26. If you request that we review your claim as an urgent

care claim, we will review the documentation you provide and decide whether or not it is an urgent

care claim by applying the judgment of a prudent layperson who possesses an average knowledge

of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive

the claim to let you know what information we need to complete our review of the claim. You will

then have up to 48 hours to provide the required information. We will make our decision on the

claim within 48 hours of (1) the time we received the additional information or (2) the end of the

time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or

electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.

Please let us know that you would like a simultaneous review of your urgent care claim by OPM

either in writing at the time you appeal our initial decision, or by calling us at the phone number

listed on the back of your ID card. You may also call OPM’s FEHB 1 at 202-606-0727 between

8 a.m. and 5 p.m. Eastern Time (excluding holidays) to ask for the simultaneous review. We will

cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not

indicate that your claim was a claim for urgent care, call us at the phone number listed on the back

of your ID card. If it is determined that your claim is an urgent care claim, we will expedite our

review (if we have not yet responded to your claim).

• Urgent care claims

25 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 3

A concurrent care claim involves care provided over a period of time or over a number of

treatments. We will treat any reduction or termination of our pre-approved course of treatment

before the end of the approved period of time or number of treatments as an appealable decision.

This does not include reduction or termination due to benefit changes or if your enrollment ends. If

we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and

obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approved time period and this is also an urgent care claim, we will make a

decision within 24 hours after we receive the request.

• Concurrent care

claims

If you have an emergency admission due to a condition that you reasonably believe puts your life in

danger or could cause serious damage to bodily function, you, your representative, the physician, or

the hospital must phone us within two business days following the day of the emergency admission,

even if you have been discharged from the hospital. If you do not phone us within two business

days, a $500 penalty may apply – see

Warning

under

Inpatient hospital admissions

earlier in this

Section and

If your facility stay needs to be extended

on this page below.

Admissions to residential treatment centers do not qualify as emergencies.

• Emergency inpatient

admission

We encourage you to notify us of your pregnancy during the first trimester. You do not need

precertification of a maternity admission for a routine delivery. However, if your medical condition

requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section,

your physician or the hospital must contact us for precertification of additional days. Further, if

your newborn stays after you are discharged, then your physician or the hospital must contact us for

precertification of additional days for your newborn.

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the

newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular

medical or surgical benefits apply rather than maternity benefits.

• Maternity care

If your hospital stay – including for maternity care – needs to be extended, you, your

representative, your physician, or the hospital must ask us to approve the additional days. If you

remain in the hospital beyond the number of days we approved and did not get the additional days

precertified, then:

• for the part of the admission that was medically necessary, we will pay inpatient benefits, but

• for the part of the admission that was not medically necessary, we will pay only medical

services and supplies otherwise payable on an outpatient basis and we will not pay inpatient

benefits.

If your residential treatment center stay needs to be extended, you, your representative, your

physician or the residential treatment center must ask us to approve the additional days. If you

remain in the residential treatment center beyond the number of days approved and did not get the

additional days precertified, we will provide benefits for medically necessary covered services,

other than room and board and inpatient physician care, at the level we would have paid if they had

been provided on an outpatient basis. Note: Benefits for inpatient residential treatment centers

(RTCs) are limited to 30 days per calendar year.

• If your facility stay

needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approved time period and this is also an urgent care claim, we will make a

decision within 24 hours after we receive the claim.

• If your treatment

needs to be extended

If you have a pre-service claim and you do not agree with our decision regarding

precertification of an inpatient admission or prior approval of

Other services

, you may request a

review by following the procedures listed on the next page. Note that these procedures apply to

requests for reconsideration of concurrent care claims as well (see page 128 for definition). If you

have already received the service, supply, or treatment, then your claim is a post-service claim and

you must follow the entire disputed claims process detailed in Section 8.

If you disagree with our

pre-service claim

decision

26 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 3

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.

Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30

days from the date we receive your written request for reconsideration to:

1. Precertify your inpatient admission or, if applicable, approve your request for prior approval for

the service, drug, or supply; or

2. Write to you and maintain our denial; or

3. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request.

We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the

information was due. We will base our decision on the information we already have. We will write

to you with our decision.

• To reconsider a non-

urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision,

you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims

process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after

receipt of your reconsideration request. We will expedite the review process, which allows verbal or

written requests for appeals and the exchange of information by phone, electronic mail, facsimile,

or other expeditious methods.

• To reconsider an

urgent care claim

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask

OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this

brochure.

• To file an appeal with

OPM

Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as

copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and

dental expenses, and much more) for you and your tax dependents, including adult children

(through the end of the calendar year in which they turn 26).

FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and

FEDVIP plans. This means that when you or your provider files claims with your FEHB or

FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based

on the claim information it receives from your plan.

• The Federal Flexible

Spending Account

Program – FSAFEDS

27 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 3

Section 4. Your Costs for Covered Services

This is what you will pay out-of-pocket for your covered care:

Cost-share or cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible,

coinsurance, and copayments) for the covered care you receive.

Note: You may have to pay the deductible, coinsurance, and/or copayment amount(s) that apply to your

care at the time you receive the services.

Cost-share/Cost-

sharing

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you

receive certain services.

Example: When you see your Preferred professional provider for physical therapy, you pay a

copayment of $25 for the visit, and we then pay the remainder of the amount we allow for the visit.

(You may have to pay separately for other services you receive while in the provider’s office.)

Copayments do not apply to services and supplies that are subject to a deductible and/or coinsurance

amount.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept

as payment in full) is less than your copayment, you pay the lower amount.

Copayment

A deductible is a fixed amount of covered expenses you must incur for certain covered services and

supplies before we start paying benefits for them. Copayments and coinsurance amounts do not count

toward your deductible. When a covered service or supply is subject to a deductible, only the Plan

allowance for the service or supply that you then pay counts toward meeting your deductible.

The calendar year deductible is $500 per person. After the deductible amount is satisfied for an

individual, covered services are payable for that individual. Under a Self Plus One enrollment, both

family members must meet the individual deductible. Under a Self and Family enrollment, an

individual may meet the individual deductible, or all family members’ individual deductibles are

considered to be satisfied when the family members’ deductibles are combined and reach $1,000.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept

as payment in full) is less than the remaining portion of your deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you

have not paid any amount toward meeting your calendar year deductible, you must pay $80. We will

apply $80 to your deductible. We will begin paying benefits once the remaining portion of your $500

calendar year deductible has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan is after January 1

of the next year, you do not have to start a new deductible under your prior plan between January 1 and

the effective date of your new plan. If you change plans at another time during the year, you must begin

a new deductible under your new plan.

Deductible

Coinsurance is the percentage of the Plan allowance that you must pay for your care. Your coinsurance

is based on the Plan allowance, or billed amount, whichever is less. Coinsurance does not begin until

you have met your calendar year deductible.

Example: You pay 30% of the Plan allowance for durable medical equipment obtained from a Preferred

provider, after meeting your $500 calendar year deductible.

Coinsurance

If your provider routinely waives (does not require you to pay) your applicable copayments,

deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case,

when we calculate our share, we will reduce the provider’s fee by the amount waived.

Example: If your physician ordinarily charges $100 for a service but routinely waives your 30%

coinsurance, the actual charge is $70. We will pay $49 (70% of the actual charge of $70).

If your provider

routinely waives your

cost

28 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 4

In some instances, a provider may ask you to sign a “waiver” prior to receiving care. This waiver may

state that you accept responsibility for the total charge for any care that is not covered by your health

plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the

contracts that the Local Plan has with its providers. If you are asked to sign this type of waiver, please

be aware that, if benefits are denied for the services, you could be legally liable for the related expenses.

If you would like more information about waivers, please contact us at the customer service phone

number on the back of your ID card.

Waivers

Our “Plan allowance” is the amount we use to calculate our payment for certain types of covered

services. Fee-for-service plans arrive at their allowances in different ways, so allowances vary. For

information about how we determine our Plan allowance, see the definition of Plan allowance in

Section 10.

Often, the provider’s bill is more than a fee-for-service Plan’s allowance. It is possible for a provider’s

bill to exceed the Plan’s allowance by a significant amount. Whether or not you have to pay the

difference between our allowance and the bill will depend on the type of provider you use. Providers

that have agreements with this Plan are Preferred and will not bill you for any balances that are in

excess of our allowance for covered services. See the descriptions appearing below for the types of

providers available in this Plan.

• Preferred providers. These types of providers have agreements with the Local Plan to limit what

they bill our members. Because of that, when you use a Preferred provider, your share of the

provider’s bill for covered care is limited.

Your share consists only of your deductible, coinsurance, and/or copayment. Here is an example

about coinsurance: You see a Preferred physician who charges $250, but our allowance is $100. If

you have met your deductible, you are only responsible for your coinsurance. That is, you pay just

30% of our $100 allowance ($30). Because of the agreement, your Preferred physician will not bill

you for the $150 difference between our allowance and his/her bill.

Remember, you must use Preferred providers in order to receive benefits. See page 18 for the

exceptions to this requirement.

• Non-preferred Providers:

- Participating provider/Member facility. There are no benefits for care performed by

Participating providers; you pay all charges. See page 18 for the exceptions to this

requirement.

- Non-participating providers/Non-member facility. There are no benefits for care performed

by Non-participating providers; you pay all charges. See page 18 for the exceptions to this

requirement.

You should also see section

Important Notice About Surprise Billing – Know Your Rights

below

that describes your protections against surprise billing under the No Surprises Act.

Differences between

our allowance and

the bill

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise

billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you

receive from a Non-participating healthcare provider, facility, or air ambulance service for healthcare.

Surprise bills can happen when you receive emergency care – when you have little or no say in the

facility or provider from whom you receive care. They can also happen when you receive non-

emergency services at participating facilities, but you receive some care from Non-participating

providers.

Balance billing happens when you receive a bill from the non-participating provider, facility, or air

ambulance service for the difference between the Non-participating provider’s charge and the amount

payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.

Important Notice

About Surprise

Billing – Know Your

Rights

29 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 4

For specific information on surprise billing, the rights and protections you have, and your

responsibilities go to www.fepblue.org/NSA or contact the customer service phone number on the back

of your ID card.

Overseas care: Services provided outside the United States, Puerto Rico, and the U.S. Virgin Islands

are considered overseas care. We pay overseas claims at Preferred benefit levels, so the requirement to

use Preferred providers in order to receive benefits does not apply. See Section 5(i) for specific

information about our overseas benefits.

Inpatient facility care: You must use Preferred facilities in order to receive benefits. See page 18 for

the exceptions to this requirement.

Your costs for other

care

We limit your annual out-of-pocket expenses for the covered services you receive to protect you from

unexpected healthcare costs. When your eligible out-of-pocket expenses reach this catastrophic

protection maximum, you no longer have to pay the associated cost-sharing amounts for the rest of the

calendar year. For Self Plus One and Self and Family enrollments, once any individual family member

reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that

member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year.

All other family members will be required to meet the balance of the catastrophic protection out-of-

pocket maximum.

Note: Certain types of expenses do not accumulate to the maximum.

Preferred Provider maximum – For a Self Only enrollment, your out-of-pocket maximum for your

deductible, and for eligible coinsurance and copayment amounts, is $8,500 when you use Preferred

providers. For a Self Plus One or a Self and Family enrollment, your out-of-pocket maximum for these

types of expenses is $17,000 for Preferred provider services. Only eligible expenses for Preferred

provider services count toward these limits.

The following expenses are not included under this feature. These expenses do not count toward your

catastrophic protection out-of-pocket maximum, and you must continue to pay them even after your

expenses exceed the limits described above.

• The difference between the Plan allowance and the billed amount. See page 29;

• Expenses for services, drugs, and supplies in excess of our maximum benefit limitations;

• The $500 penalty for failing to obtain precertification, and any other amounts you pay because we

reduce benefits for not complying with our cost containment requirements;

• The $100 penalty for failing to obtain prior approval, and any other amounts you pay because we

reduce benefits for not complying with our cost containment requirements;

• If there is a generic substitution available and you or your provider requests a brand-name drug,

your expenses for the difference between the cost of the generic medication and the brand-name

medication do not count toward your catastrophic protection out-of-pocket maximum (see page 91

for additional information); and

• Expenses for care received from Non-preferred providers (Participating/Non-participating

professional providers or Member/Non-member facilities), except for your deductible, coinsurance

and/or copayments you pay in those situations where we do pay for care provided by Non-preferred

providers. Please see page 18 for the exceptions to the requirement to use Preferred providers.

Your catastrophic

protection out-of-

pocket maximum for

deductibles,

coinsurance, and

copayments

If you change to another plan during Open Season, we will continue to provide benefits between

January 1 and the effective date of your new plan.

• If you had already paid the out-of-pocket maximum, we will continue to provide benefits as

described above until the effective date of your new plan.

• If you had not yet paid the out-of-pocket maximum, we will apply any expenses you incur in

January (before the effective date of your new plan) to our prior year’s out-of-pocket maximum.

Once you reach the maximum, you do not need to pay our deductibles, copayments, or coinsurance

amounts (except as shown above) from that point until the effective date of your new plan.

Carryover

30 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 4

Because benefit changes are effective January 1, we will apply our next year’s benefits to any expenses

you incur in January.

If you change options in this Service Benefit Plan during the year, we will credit the amounts already

accumulated toward the catastrophic protection out-of-pocket limit of your old option to the

catastrophic protection out-of-pocket limit of your new option. If you change from Self Only to Self

Plus One or Self and Family, or vice versa, during the calendar year, please call us about your out-of-

pocket accumulations and how they carry over.

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may

reduce subsequent benefit payments to offset overpayments.

We will generally first seek recovery from the provider if we paid the provider directly, or from the

person (covered family member, guardian, custodial parent, etc.) to whom we sent our payment.

If we provided coverage in error, but in good faith, for prescription drugs purchased through one of our

pharmacy programs, we will request reimbursement from the contract holder.

If we overpay you

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health

Service are entitled to seek reimbursement from us for certain services and supplies they provide to you

or a family member. They may not seek more than their governing laws allow. You may be responsible

to pay for certain services and charges. Contact the government facility directly for more information.

When Government

facilities bill us

31 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Section 4

Section 5. FEP Blue Focus Benefits

FEP Blue Focus

See page 15 for how our benefits changed this year. Page 139 is a summary of benefits for this plan and pages 34-37 provide an

overview of FEP Blue Focus.

Section 5. FEP Blue Focus Overview .........................................................................................................................................34

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals ..............................38

Diagnostic and Treatment Services ...................................................................................................................................39

Lab, X-ray and Other Diagnostic Tests .............................................................................................................................40

Preventive Care, Adult ......................................................................................................................................................41

Preventive Care, Child ......................................................................................................................................................44

Maternity Care ..................................................................................................................................................................45

Family Planning ................................................................................................................................................................47

Reproductive Services .......................................................................................................................................................47

Allergy Care ......................................................................................................................................................................48

Treatment Therapies ..........................................................................................................................................................49

Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy ................................50

Hearing Services ...............................................................................................................................................................50

Vision Services (Testing, Treatment, and Supplies) .........................................................................................................51

Foot Care ...........................................................................................................................................................................52

Orthopedic and Prosthetic Devices ...................................................................................................................................52

Durable Medical Equipment (DME) .................................................................................................................................53

Medical Supplies ...............................................................................................................................................................54

Home Health Services .......................................................................................................................................................54

Alternative/Manipulative Treatment .................................................................................................................................55

Educational Classes and Programs ...................................................................................................................................55

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals ..........................56

Surgical Procedures ...........................................................................................................................................................57

Reconstructive Surgery .....................................................................................................................................................59

Oral and Maxillofacial Surgery .........................................................................................................................................61

Organ/Tissue Transplants ..................................................................................................................................................66

Anesthesia .........................................................................................................................................................................68

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................69

Inpatient Hospital ..............................................................................................................................................................70

Maternity – Facility ...........................................................................................................................................................71

Outpatient Hospital or Ambulatory Surgical Center .........................................................................................................73

Residential Treatment Center ............................................................................................................................................76

Extended Care Benefits/Skilled Nursing Care Facility Benefits ......................................................................................77

Hospice Care .....................................................................................................................................................................77

Ambulance ........................................................................................................................................................................80

Section 5(d). Emergency Services/Accidents .............................................................................................................................81

Accidental Injury ...............................................................................................................................................................82

Medical Emergency ..........................................................................................................................................................83

Ambulance ........................................................................................................................................................................84

Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................85

Professional Services ........................................................................................................................................................85

Inpatient Hospital or Other Covered Facility ....................................................................................................................87

Residential Treatment Center ............................................................................................................................................87

Outpatient Hospital or Other Covered Facility .................................................................................................................88

Section 5(f). Prescription Drug Benefits .....................................................................................................................................89

32 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5

FEP Blue Focus

Covered Medications and Supplies ...................................................................................................................................93

Section 5(g). Dental Benefits ....................................................................................................................................................101

Accidental Injury Benefit ................................................................................................................................................101

Inpatient and Outpatient Facility Care ............................................................................................................................102

Section 5(h). Wellness and Other Special Features ...................................................................................................................103

Health Tools ....................................................................................................................................................................103

Services for the Deaf and Hearing Impaired ...................................................................................................................103

Web Accessibility for the Visually Impaired ...................................................................................................................103

Travel Benefit/Services Overseas ...................................................................................................................................103

Healthy Families .............................................................................................................................................................103

Blue Health Assessment ..................................................................................................................................................103

Hypertension Management Program ..............................................................................................................................103

MyBlue® Customer eService .........................................................................................................................................104

National Doctor & Hospital Finder .................................................................................................................................104

Care Management Programs ...........................................................................................................................................104

Flexible Benefits Option .................................................................................................................................................105

Telehealth Services .........................................................................................................................................................105

Routine Annual Physical Incentive Program ..................................................................................................................106

The fepblue Mobile Application .....................................................................................................................................106

Section 5(i). Services, Drugs, and Supplies Provided Overseas ...............................................................................................107

Non-FEHB Benefits Available to Plan Members ......................................................................................................................110

33 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5

Section 5. FEP Blue Focus Overview

FEP Blue Focus

The benefit package for FEP

Blue Focus is described in Section 5, which is divided into subsections 5(a) through 5(i).

Please read

Important things you should keep in mind

at the beginning of the subsections. Also read the general exclusions in Section

6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about FEP

Blue Focus benefits, contact us at the customer service phone number on the back of your ID card or go to our website at www.

fepblue.org.

We have provided a new way for you to consider the benefits available to you under FEP Blue Focus to determine whether this

product will be a good choice for you and your family. We have divided the benefits under FEP Blue Focus into three basic categories:

CORE, NON-CORE and WRAP. The following information describes the portion you pay, based on the benefits you use. All benefits

are subject to the definitions, limitations, and exclusions in this brochure. In the following charts, we summarize specific expenses we

cover; for more detail, look inside. Do not rely on the charts alone. Note: For more information about services received overseas, see

Section 5(i).

The “

CORE

” benefits are those under this program that form the most important level – the base of the program. These benefits have

only a low or no copayment and are not subject to a deductible or coinsurance for the care received. These benefits are most

commonly used to receive general care and to maintain your overall health and well-being, in addition to coverage for accidental

injuries. For example, your first 10 healthcare visits with a primary care physician, specialist or other healthcare professional will be

subject to a $10 copayment for each visit.

The “

NON-CORE

” benefits are there to provide coverage for any unexpected medical costs you may incur during the calendar year.

These share the same annual deductible and the same co-insurance level (see

Annual Cost-Shares

below). When the catastrophic out-

of-pocket maximum has been satisfied, we pay 100% of the Plan allowance for the remainder of the calendar year (see page 30 for

more information). For example, after your first 10 visits (primary care, specialist or other healthcare provider), you will have a

deductible to satisfy of $500 and then you will pay 30% of the Plan allowance for the visit. You may or may not have a need to use

these benefits during the year.

“

WRAP

” benefits provide the final layer of protection and complete or “wrap-up” the FEP Blue Focus benefit package. These are

benefits you may or may not have a need to use during the year. These benefits have visit limitations and/or different copayments or

co-insurance levels than the “CORE” or “NON-CORE” benefit levels. The calendar year deductible does not apply to these benefits.

In addition to the general exclusions found in Section 6, this program does not provide benefits for some services that are covered

under the Service Benefit Plan Standard or Basic Options. An example of services excluded under FEP Blue Focus is coverage for

routine dental care. See the charts below.

You must use Preferred providers for your care to be eligible for benefits, except in certain circumstances, such as medical

emergency or accidental injury services. Preferred providers will submit claims to us on your behalf.

ANNUAL COST-

See above for information about when these cost-shares apply.

Cost-Share Member Responsibility (Self Only) Member Responsibility (Self Plus One/

Self and Family)

Deductible $500 $1,000

Coinsurance (medical) 30% of the Plan Allowance 30% of the Plan Allowance

Catastrophic Maximum $8,500 $17,000

34 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5

FEP Blue Focus

CORE

Key benefits with no or low member cost-share – not subject to deductible and coinsurance

Brochure

Section

Benefit Member Payment &

Calendar Year Limitations

Page(s)

5(a) Professional visit (combined medical and mental

health and substance use disorder visits, see

Section 5(e))

$10 per visit for first 10 visits (See “Non-

Core” for visits 11+.)

39, 86

5(a) Lab, X-ray and other diagnostic services $0 member cost-share for the first 10

laboratory tests performed in each of these

different laboratory test categories (Basic

metabolic panels; Cholesterol screenings;

Complete blood counts; Fasting lipoprotein

profiles; General health panels; Urinalysis)

and 10 Venipunctures when not associated

with preventive, maternity or accidental

injury care

5(a) Telehealth

• Minor acute conditions

• Dermatology care

• Mental health and substance use disorder

counseling

$10 per visit

First 2 visits – no member cost-share

39, 86

5(a) Preventive care (adult/child) $0 41, 44

5(a) Family planning $0 47

5(a) Oral & transdermal contraceptives from Preferred

pharmacy

$0 95

5(a) Immunizations (preventive) $0 42, 44

5(a) Smoking cessation treatment $0 55, 98

5(a) Acupuncture and manipulative treatments $25 per visit

Limited to 10 visits combined

5(c), 5(d) & 5(g) Accidental injury

• Ambulance

• Dental

• Professional

• Outpatient hospital services

• Urgent Care

Within 72 hours of the accidental injury

80, 82,

101

5(d) Medical emergencies – urgent care $25 per visit 83

5(f) Preferred retail pharmacy - Tier 1: (Preferred

Generic Drugs at a Preferred retail pharmacy)

$5 for up to a 30-day supply

$15 for up to a 90-day supply

*The Core benefits do not include Tier 2 brand-name drugs or any specialty drugs (including generic specialty drugs), see

WRAP benefits listed on page 37.

35 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5

FEP Blue Focus

NON-CORE

Benefits that share a common deductible and coinsurance

Brochure

Section

Benefit Member Payment & Calendar Year

Limitations (Deductible Applies)

Page(s)

5(a) Professional visits (combined medical and mental

health and substance use disorder visits, see

Section 5(e))

30% of the Plan Allowance

Beginning with visit 11 and after

39, 86

5(a) Inpatient physician 30% of the Plan Allowance 39-40

5(a) Lab, X-ray and other diagnostic services 30% of the Plan Allowance 40-41

5(a) Lab, X-ray and other diagnostic services Beginning with the 11

occurrence of

laboratory tests performed in each of these

different laboratory test categories (Basic

metabolic panels; Cholesterol screenings;

Complete blood counts; Fasting lipoprotein

profiles; General health panels; Urinalysis)

and Venipunctures when not associated with

preventive, maternity or accidental injury

care, 30% of Plan Allowance after CYD

5(a) Allergy – testing, injections, multi-dose antigens 30% of the Plan Allowance 48

5(a) Outpatient applied behavior analysis (ABA) 30% of the Plan Allowance

Limited to 200 hours

49, 75

5(a) Inpatient and outpatient therapies 30% of the Plan Allowance 49

5(a) Durable medical equipment 30% of the Plan Allowance 53

5(b) Surgical care – including Blue Distinction

Center 30% of the Plan Allowance 57-68

5(c) Inpatient hospital 30% of the Plan Allowance 70-71

5(c) Outpatient hospital or ambulatory surgical center 30% of the Plan Allowance 73-76

5(c) Ambulance – medical emergency 30% of the Plan Allowance 80

5(c) & 5(e) Inpatient residential treatment centers (RTCs) 30% of the Plan Allowance

Limited to 30 days

76, 87

5(d) Accidental injury – inpatient 30% of the Plan Allowance 82

5(d) Medical emergencies (Professional, Hospital

emergency room)

30% of the Plan Allowance 83

5(e) Mental health visits (combined medical and mental

health and substance use disorder visits, see

Section 5(e))

30% of the Plan Allowance

Beginning with visit 11 and after

5(e) Mental health inpatient and outpatient professional 30% of the Plan Allowance 86

5(e) Mental health inpatient, outpatient, and intensive

outpatient care – facility

30% of the Plan Allowance 87-88

36 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5

FEP Blue Focus

WRAP

Benefits with different copayments or coinsurance and no deductible - limits may apply

Brochure

Section

Benefit Member Payment &

Calendar Year Limitations

Page(s)

5(a) Maternity – professional $0 45

5(c) Maternity – facility $1,500 per pregnancy 71-72

5(a) Occupational, physical or speech therapy $25/visit

Limited to 25 visits combined

5(c) Hospice – Traditional (home) $0 79

5(f) Preferred retail pharmacy – Tier 2 (Preferred

Brand-name drugs)

40% of the Plan allowance (up to a $350

maximum) for up to a 30-day supply

40% of the Plan allowance (up to a $1,050

maximum) for up to a 90-day supply

5(f) Specialty pharmacy – Tier 2 (Preferred Generic

Specialty drugs and Preferred Brand-name

Specialty Drugs)

40% of the Plan allowance (up to a $350

maximum) for up to a 30-day supply

NOT COVERED

See “Not covered” at the end of each sub-section and Section 6, General Exclusions, page 111, for complete information

regarding services, drugs or supplies not covered under FEP Blue Focus.

Benefit Member Payment

Hearing aids including bone-anchored hearing aids

All charges

Wigs

All charges

Skilled nursing facility

All charges

Non-preferred generic, non-preferred brand-name and non-preferred specialty generic and brand-

name drugs (drugs not on the FEP Blue Focus formulary)

All charges

Dental care (except accidental injury)

All charges

37 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5

Section 5(a). Medical Services and Supplies Provided by Physicians and Other

Healthcare Professionals

FEP Blue Focus

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure

and are payable only when we determine they are medically necessary.

•Please refer to Section 3,

How You Get Care

, for information on covered professional providers and other

healthcare professionals.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how cost-sharing

works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age

65 or over.

•We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will

find that some benefits are listed in more than one Section of the brochure. This is because how they are paid

depends on what type of provider or facility bills for the service.

•The services listed in this Section are for the charges billed by a physician or other healthcare professional

for your medical care. See Section 5(c) for charges associated with the facility (i.e., hospital or other

outpatient facility, etc.).

•Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drugs

when obtained from a covered provider other than a pharmacy under the pharmacy benefit. You must use a

Preferred pharmacy, thereafter. This benefit limitation does not apply if you have primary Medicare Part B

coverage. See page 93 for information about Tier 2 specialty drug fills from a Preferred pharmacy.

Medications restricted under this benefit are available on our FEP Blue Focus Specialty Drug List. Visit

www.fepblue.org/specialtypharmacy or call us at 888-346-3731.

•The calendar year deductibles: $500 per person ($1,000 per Self Plus One or Self and Family enrollment).

We state whether or not the calendar year deductible applies for each benefit listed in this section.

•You must use Preferred providers in order to receive benefits. See below and page 18 for the exceptions

to this requirement.

•We provide benefits at Preferred benefit levels for services provided in Preferred facilities by Non-preferred

radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room

physicians, and assistant surgeons (including assistant surgeons in a physician’s office). You may be

responsible for any difference between our payment and the billed amount. See page 29, NSA, for

information on when you are not responsible for this difference.

•You should be aware that some Non-preferred (non-PPO) professional providers may provide services in

Preferred (PPO) facilities.

•There is a $10 visit copayment for each of the first 10 visits to a professional provider per calendar year. This

applies to a combined total for medical and mental health and substance use disorder visits.

•We waive the cost-share for the first 2 visits for telehealth per calendar year. This applies to a combined total

for treatment of minor acute conditions, dermatology care, and mental health and substance use disorder

conditions. (See pages 39 and 86.)

•If you receive both preventive and diagnostic services from your Preferred provider on the same day,

you are responsible for paying your cost-share for the diagnostic services. This includes applicable cost-share

for diagnostic procedures such as an injection, laboratory, and X-ray services.

•An incentive award is available for those members (member and/or Spouse over age 18) who receive an

annual routine physical in 2022. Please see Section 5(h), page 106, for more information.

38 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Preventive Care Benefits - Here are some things to keep in mind:

•Preventive care refers to medical services, counseling, and screenings related to the prevention of disease and

health-related problems, rather than curing disease or treating its symptoms.

•You must use Preferred providers in order to receive preventive benefits without cost-share, see page 18 for

exceptions to this requirement.

Benefit Description You Pay

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Diagnostic and Treatment Services FEP Blue Focus

Outpatient professional services of physicians and other healthcare

professionals:

• Consultations

• Genetic counseling

• Second surgical opinions

• Clinic visits

• Office visits

• Home visits

• Initial examination of a newborn needing definitive treatment when

covered under a Self Plus One or Self and Family enrollment

• Pharmacotherapy (medication management) (See Section 5(f) for

prescription drug coverage)

• Phone consultations and online medical evaluation and management

services (telemedicine)

Note: Please refer to pages 40-41 for our coverage of laboratory, X-ray, and

other diagnostic tests billed for by a healthcare professional, and to page 74

for our coverage of these services when billed for by a facility, such as the

outpatient department of a hospital.

Preferred provider: $10 copayment (no deductible)

per visit up to a combined total of 10 visits per

calendar year (benefits combined with visits in

Section 5(e) page 86)

Preferred provider, visits after the 10

visit: 30%

of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: You pay 30% of the Plan

allowance (deductible applies) for agents, drugs,

and/or supplies administered or obtained in

connection with your care. (See page 128 for more

information about “agents.”)

Telehealth professional services for:

• Minor acute conditions (see page 131 for definition)

• Dermatology care (see page 135 for definition)

Notes:

• Refer to Section 5(h),

Wellness and Other Special Features

, for information

on telehealth services and how to access a provider.

• Copayments are waived for members with Medicare Part B primary.

Preferred Telehealth Provider: Nothing (no

deductible) for the first 2 visits per calendar year

for any covered telehealth service (benefits are

combined with telehealth services listed in Section

5(e) page 86)

$10 copayment per visit (no deductible) after the

visit

Non-preferred (Participating/Non-participating):

You pay all charges

Inpatient professional services:

• During a covered hospital stay

• Services for nonsurgical procedures when ordered, provided, and billed by

a physician during a covered inpatient hospital admission

• Medical care by the attending physician (the physician who is primarily

responsible for your care when you are hospitalized) on days we pay

hospital benefits

Note: A consulting physician employed by the hospital is not the attending

physician.

• Consultations when requested by the attending physician

• Nutritional counseling when billed by a covered provider

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Diagnostic and Treatment Services - continued on next page

39 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Diagnostic and Treatment Services (cont.) FEP Blue Focus

• Concurrent care – hospital inpatient care by a physician other than the

attending physician for a condition not related to your primary diagnosis, or

because the medical complexity of your condition requires this additional

medical care

• Physical therapy by a physician other than the attending physician

• Initial examination of a newborn needing definitive treatment when

covered under a Self Plus One or Self and Family enrollment

• Pharmacotherapy (medication management) (See Section 5(c) for our

coverage of drugs you receive while in the hospital.)

• Second surgical opinion

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Routine services except for those Preventive care services described on

pages 41 -45

•

Costs associated with enabling or maintaining providers’ telehealth

(telemedicine) technologies, non-interactive telecommunication such as

email communications, or asynchronous store-and-forward telehealth

services

•

Private duty nursing

•

Standby physicians

•

Routine radiological and staff consultations required by facility rules and

regulations

•

Inpatient physician care when your admission or portion of an admission is

not covered (See Section 5(c).)

Note: If we determine that an inpatient admission is not covered, we will

not provide benefits for inpatient room and board or inpatient physician

care. However, we will provide benefits for covered services or supplies

other than room and board and inpatient physician care at the level that we

would have paid if they had been provided in some other setting.

All charges

Lab, X-ray and Other Diagnostic Tests FEP Blue Focus

Diagnostic tests, such as:

• Laboratory tests (such as blood tests and urinalysis)

• Pathology services

• EKGs

• Cardiovascular monitoring

• EEGs

• Neurological testing

• Ultrasounds

• X-rays (including set-up of portable X-ray equipment)

• Bone density tests

• CT scans*/MRIs*/PET scans*

• Angiographies

• Genetic testing*

*Prior approval is required

Preferred: 30% of the Plan allowance (deductible

applies)

Note: $0 member cost-share for the first 10

laboratory tests performed in each of these

different laboratory test categories (Basic

metabolic panels; Cholesterol screenings;

Complete blood counts, Fasting lipoprotein

profiles; General health panels; Urinalysis) and 10

Venipunctures when not associated with preventive

maternity or accidental injury care.

Non-preferred (Participating/Non-participating):

You pay all charges

Lab, X-ray and Other Diagnostic Tests - continued on next page

40 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Lab, X-ray and Other Diagnostic Tests (cont.) FEP Blue Focus

• Notes:

- Benefits are available for specialized diagnostic genetic testing when it is

medically necessary to diagnose and/or manage a patient’s existing

medical condition. Benefits are not provided for genetic panels when

some or all of the tests included in the panel are not covered, are

experimental or investigational, or are not medically necessary. Refer to

the next paragraph for information about diagnostic BRCA.

- You must obtain prior approval for BRCA testing (see page 43).

Diagnostic BRCA testing, including testing for large genomic

rearrangements in the BRCA1 and BRCA2 genes: Benefits are available

for members with a cancer diagnosis when the requirements in the note

above are met, and the member does not meet criteria for Preventive

BRCA testing. Benefits are limited to one test of each type per lifetime

whether covered as a diagnostic test or paid under

Preventive Care

benefits (see page 43).

- See page 43 in this Section for coverage of genetic counseling and

testing services related to family history of cancer or other disease.

• Nuclear medicine

• Sleep studies

Note: See Section 5(c) for services billed for by a facility, such as the

outpatient department of a hospital.

Continued from previous page:

Note: When care is provided by a Non-preferred

laboratory and/or radiologist, as stated on page 18

for an exception, you pay:

• Participating laboratories or radiologists: 30% of

the Plan allowance (deductible applies)

• Non-participating laboratories or radiologists:

30% of the Plan allowance, plus any difference

between our allowance and the billed amount

(deductible applies)

Preventive Care, Adult FEP Blue Focus

Benefits are provided for preventive care services for adults age 22 and over.

Covered services include:

• Counseling on prevention and reducing health risks

• Nutritional counseling

Note: When nutritional counseling is via the contracted telehealth provider

network, we provide benefits as shown here for Preferred providers. Refer

to Section 5(h), Wellness and Other Special Features, for information on

how to access a telehealth provider.

• Visits/exams for preventive care

Note: See the definition of Preventive Care, Adult, on page 134 for

included health screening services.

Preventive care benefits for each of the services listed below are limited to

one per calendar year.

• Administration and interpretation of a Health Risk Assessment (HRA)

questionnaire (see

Definitions

)

Note: As a member of FEP Blue Focus, you have access to the Blue Cross

and Blue Shield HRA, called the “Blue Health Assessment” questionnaire.

See Section 5(h) for more information.

• Basic or comprehensive metabolic panel test

• CBC

• Cervical cancer screening tests

- Human papillomavirus (HPV) tests of the cervix

- Pap tests of the cervix

Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: When care is provided by a Non-preferred

laboratory and/or radiologist, as stated on page 18

for an exception, you pay:

• Participating laboratories or radiologists:

Nothing (no deductible)

• Non-participating laboratories or radiologists:

The difference between our allowance and the

billed amount (no deductible)

Note: See Section 5(c) for our payment levels for

covered cancer screenings and ultrasound

screening for abdominal aortic aneurysm billed for

by Member or Non-member facilities and

performed on an outpatient basis.

Note: For services billed by Non-preferred

providers (Participating/Non-participating) related

to Influenza (flu) vaccines, we pay the Plan

allowance. If you receive the Influenza (flu)

vaccine from a Non-participating provider, you pay

any difference between our allowance and the

billed amount (no deductible).

Preventive Care, Adult - continued on next page

41 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Preventive Care, Adult (cont.) FEP Blue Focus

• Colorectal cancer tests, including:

- Colonoscopy with or without biopsy (see page 57 for our payment levels

for diagnostic colonoscopies)

- DNA analysis of stool samples

- Double contrast barium enema

- Fecal occult blood test

- Sigmoidoscopy

• Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or

triglycerides)

• General health panel

• Prostate cancer tests – Prostate Specific Antigen (PSA) test

• Screening for chlamydial infection

• Screening for diabetes mellitus

• Screening for gonorrhea infection

• Screening for human immunodeficiency virus (HIV)

• Screening mammograms, including mammography using digital

technology

• Ultrasound for abdominal aortic aneurysm for adults, ages 65 to 75, limited

to one screening per lifetime

• Urinalysis

The following preventive services are covered at the time interval

recommended at each of the links below as adopted by December 31, 2020.

• Immunizations such as COVID-19, Pneumococcal, influenza, shingles,

tetanus/DTaP) and human papillomavirus (HPV). For a complete list of

immunizations go to the Centers for Disease Control (CDC) website at

https://www.cdc.gov/vaccines/schedules.

Note: U.S. FDA licensure may restrict the use of the immunizations and

vaccines listed above to certain age ranges, frequencies, and/or other

patient-specific indications, including gender.

• USPSTF A and B recommended screenings such as cancer, osteoporosis,

depression, and high blood pressure. For a complete list of covered A and B

recommendation screenings and age and frequency limitations go to the U.

S. Preventive Services Task Force (USPSTF) website at https://www.

uspreventiveservicestaskforce.org

• Well woman care such as gonorrhea prophylactic medication to protect

newborns, annual counseling for sexually transmitted infections,

contraceptive methods, and screening for interpersonal and domestic

violence. For a complete list of Well Women preventive care services go to

the Health and Human Services (HHS) website at https://www.healthcare.

gov/preventive-care-women/

• To build your personalized list of preventive services go to https://health.

gov/myhealthfinder

Continued from previous page:

Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: When care is provided by a Non-preferred

laboratory and/or radiologist, as stated on page 18

for an exception, you pay:

• Participating laboratories or radiologists:

Nothing (no deductible)

• Non-participating laboratories or radiologists:

The difference between our allowance and the

billed amount (no deductible)

Note: See Section 5(c) for our payment levels for

covered cancer screenings and ultrasound

screening for abdominal aortic aneurysm billed for

by Member or Non-member facilities and

performed on an outpatient basis.

Note: For services billed by Non-preferred

providers (Participating/Non-participating) related

to Influenza (flu) vaccines, we pay the Plan

allowance. If you receive the Influenza (flu)

vaccine from a Non-participating provider, you pay

any difference between our allowance and the

billed amount (no deductible).

Note: Many Preferred retail pharmacies participate

in our vaccine network. See page 95 for our

coverage of these vaccines when provided by

pharmacies in the vaccine network.

Preventive Care, Adult - continued on next page

42 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Preventive Care, Adult (cont.) FEP Blue Focus

Notes:

• We pay preventive care benefits on the first claim we process for each of

the above tests you receive in the calendar year. Regular coverage criteria

and benefit levels apply to subsequent claims for those types of tests if

performed in the same year. If you receive both preventive and diagnostic

services from your Provider on the same day, you are responsible for

paying your cost-share for the diagnostic services. Any procedure,

injection, diagnostic service, laboratory, or X-ray service done in

conjunction with a routine examination not included in the preventive

recommended listing of services will be subject to the applicable member

copayments, coinsurance and deductible.

• See page 96 for our payment levels for medications to promote better

health as recommended under the Affordable Care Act.

• See page 97 for our payment levels for bowel preparation medications, and

antiretroviral medications for the prevention of HIV.

• Unless otherwise noted, the benefits listed above and on pages 41-42 do not

apply to children up to age 22. (See benefits under

Preventive Care, Child

in this Section.)

See previous page

Hereditary Breast and Ovarian Cancer Screening

Benefits are available for screening members, age 18 and over (including

children ages 18 – 21) limited to one of each type of test per lifetime, to

evaluate the risk for developing certain types of hereditary breast or ovarian

cancer related to mutations in BRCA1 and BRCA2 genes:

• Genetic counseling and evaluation for members whose personal and/or

family history is associated with an increased risk for harmful mutations in

BRCA1 and BRCA2 genes.

• BRCA testing for members whose personal and/or family history is

associated with an increased risk for harmful mutations in BRCA1 or

BRCA2 genes.

Notes:

• You must receive genetic counseling and evaluation services and obtain

prior approval before you receive preventive BRCA testing. Preventive

care benefits will not be provided for BRCA testing unless you receive

genetic counseling and evaluation prior to the test, and scientifically valid

screening measures are used for the evaluation, and the results support

BRCA testing. See page 19 for information about prior approval and

additional BRCA coverage or call the phone number on the back of your ID

card for additional policy information.

• See page 57 for the benefits available for the surgical removal of breast,

ovaries, or prostate cancer when screening reveals a BRCA mutation:

preventive care benefits are not available.

Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: When care is provided by a Non-preferred

laboratory and/or radiologist, as stated on page 18

for an exception, you pay:

• Participating laboratories or radiologists:

Nothing (no deductible)

• Non-participating laboratories or radiologists:

The difference between our allowance and the

billed amount (no deductible)

Note: When billed by a Preferred facility, such as

the outpatient department of a hospital, we provide

benefits for Preferred providers. Benefits are not

available for BRCA testing performed at Member

or Non-member facilities.

Not covered:

•

Genetic testing related to family history of cancer or other disease, except

as described above

Note: See page 40 for our coverage of medically necessary diagnostic

genetic testing.

All charges

Preventive Care, Adult - continued on next page

43 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Preventive Care, Adult (cont.) FEP Blue Focus

•

Genetic panels when some or all of the tests included in the panel are not

covered, are experimental or investigational, or are not medically necessary

•

Self-administered health risk assessments (other than the Blue Health

Assessment)

•

Screening services requested solely by the member, such as commercially

advertised heart scans, body scans, and tests performed in mobile traveling

vans

•

Physical exams required for obtaining or continuing employment or

insurance, attending schools or camp, athletic exams, or travel

•

Immunizations, boosters, and medications for travel or work-related

exposure. Medical benefits may be available for these services.

•

Phone consultations and online medical evaluation and management

services (telemedicine) for preventive services, except as noted on page 41

for nutritional counseling

All charges

Preventive Care, Child FEP Blue Focus

Benefits are provided for preventive care services for children up to age 22.

This includes:

• Well-child visits, examinations, and other preventive services as adopted by

December 31, 2020, and described in the Bright Future Guidelines as

provided by the American Academy of Pediatrics. For a complete list of the

American Academy of Pediatrics Bright Future Guidelines go to https://

brightfutures.aap.org

• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella

(MMR), and Varicella. For a complete list of immunizations go to the

Centers for Disease Control (CDC) website at https://www.cdc.gov/

vaccines/schedules/index.html

Note: U.S. FDA licensure may restrict the use of certain vaccines to

specific age ranges, frequencies, and/or other patient-specific indications,

including gender.

• To build your personalized list of preventive services go to https://health.

gov/myhealthfinder

Note: Preventive care benefits for each of the services listed below are limited

to one per calendar year:

• Screening for hepatitis B for children age 13 and over

• Screening for chlamydial infection

• Screening for gonorrhea infection

• Cervical cancer screening tests

- Human papillomavirus (HPV) tests of the cervix

- Pap tests of the cervix

Note: See page 43 for covered BRCA testing.

• Screening for human immunodeficiency virus (HIV) infection

• Screening for syphilis infection

• Screening for latent tuberculosis infection for children ages 18 through 21

• Nutritional counseling

Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: When care is provided by a Non-preferred

laboratory and/or radiologist, as stated on page 18

for an exception, you pay:

• Participating laboratories or radiologists:

Nothing (no deductible)

• Non-participating laboratories or radiologists:

The difference between our allowance and the

billed amount (no deductible)

Notes:

• For services billed by Non-preferred providers

(Participating/Non-participating) related to

Influenza (flu) vaccines, we pay the Plan

allowance. If you receive the Influenza (flu)

vaccine from a Non-participating provider, you

pay any difference between our allowance and

the billed amount (no deductible).

• When billed by a facility, such as the outpatient

department of a hospital, we provide benefits as

shown here, according to the contracting status

of the facility.

Preventive Care, Child - continued on next page

44 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Preventive Care, Child (cont.) FEP Blue Focus

Note: If your child receives both preventive and diagnostic services from a

Preferred provider on the same day, you are responsible for paying the cost-

share for the diagnostic services.

Note: When nutritional counseling is via the contracted telehealth provider

network, we provide benefits as shown here for Preferred providers. Refer to

Section 5(h),

Wellness and Other Special Features

, for information on how to

access a telehealth provider.

Any procedure, injection, diagnostic service, laboratory, or X-ray service done

in conjunction with a routine examination and not included in the preventive

listing of services will be subject to the applicable member copayments,

coinsurance, and deductible.

See page 96 for our payment levels for medications to promote better health

as recommended under the Affordable Care Act.

See previous page

Not covered:

•

Self-administered health risk assessments (other than the Blue Health

Assessment)

•

Screening services requested solely by the member, such as commercially

advertised heart scans, body scans, and tests performed in mobile traveling

vans

•

Physical exams required for obtaining or continuing employment or

insurance, attending schools or camp, athletic exams, or travel

•

Immunizations, boosters, and medications for travel or work-related

exposure. Medical benefits may be available for these services.

•

Phone consultations and online medical evaluation and management

services (telemedicine) for preventive services, except as noted above for

nutritional counseling.

All charges

Maternity Care FEP Blue Focus

We encourage you to notify us of your pregnancy during the first trimester,

see page 24.

Maternity (obstetrical) care including related conditions resulting in childbirth

or miscarriage, such as:

• Prenatal care (including ultrasound, laboratory, and diagnostic tests)

• Delivery

• Postpartum care

Note: We cover up to 4 visits per year in full to treat depression associated

with pregnancy (i.e., depression during pregnancy, postpartum depression,

or both) when you use a Preferred provider. See Section 5(e) for our

coverage and benefits for additional mental health services.

• Assistant surgeons/surgical assistance if required because of the complexity

of the delivery

• Anesthesia (including acupuncture) when requested by the attending

physician and performed by a certified registered nurse anesthetist (CRNA)

or a physician other than the operating physician (surgeon) or the assistant

• Tocolytic therapy and related services when provided on an inpatient basis

during a covered hospital admission or during a covered observation stay

Preferred: Nothing (no deductible)

Note: For Preferred facility care related to

maternity, including care at Preferred birthing

facilities, your responsibility for covered facility

care is limited to $1,500 per pregnancy. See

Section 5(c), page 71.

Non-preferred (Participating/Non-participating):

You pay all charges

Note: When care is provided by a Non-preferred

laboratory and/or radiologist, as stated on page 18

for an exception, you pay:

• Participating laboratories or radiologists:

Nothing (no deductible)

• Non-participating laboratories or radiologists:

The difference between our allowance and the

billed amount (no deductible)

Maternity Care - continued on next page

45 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Maternity Care (cont.) FEP Blue Focus

• Breastfeeding education and individual coaching on breastfeeding by

healthcare providers such as physicians, physician assistants, midwives,

nurse practitioners/clinical specialists, and lactation consultants

Note: See below for our coverage of breast pump kits.

• Home nursing visits (skilled), subject to visit limitation stated on page 54

Notes:

• See pages 41 and 44 for our coverage of nutritional counseling.

• Maternity care benefits are not provided for prescription drugs required

during pregnancy, except as recommended under the Affordable Care Act.

See page 96 for more information. See Section 5(f) for other prescription

drug coverage.

Here are some things to keep in mind:

• You do not need to precertify your delivery; see page 26 for other

circumstances, such as extended stays for you or your newborn.

• You may remain in the hospital up to 48 hours after a vaginal delivery and

96 hours after a cesarean delivery. We will cover an extended stay if

medically necessary.

• We cover routine nursery care of the newborn when performed during the

covered portion of the mother’s maternity stay and billed by the facility. We

cover other care of a newborn who requires professional services or non-

routine treatment, only if we cover the newborn under a Self Plus One or

Self and Family enrollment. Surgical benefits apply to circumcision when

billed by a professional provider for a male newborn.

• Hospital services are listed in Section 5(c) and Surgical benefits are in

Section 5(b).

• See page 132 for our payment for inpatient stays resulting from an

emergency delivery at a hospital or other facility not contracted with your

Local Plan.

• When a newborn requires definitive treatment during or after the mother’s

confinement, the newborn is considered a patient in their own right.

Regular medical or surgical benefits apply rather than maternity benefits.

• See page 57 for our payment levels for circumcision.

See previous page

• Breast pump limited to one per calendar year for members who are

pregnant and/or nursing

Note: Milk storage bags will be included with your breast pump.

Note: Benefits for the breast pump and milk storage bags are only available

when you order them through our fulfillment vendor by visiting www.fepblue.

org/maternity or calling 1-800-411-2583.

Nothing

Not covered:

•

Procedures, services, drugs, and supplies related to abortions except when

the life of the mother would be endangered if the fetus were carried to term

or when the pregnancy is the result of an act of rape or incest

•

Genetic testing/screening of the baby’s father (see page 40 for our coverage

of medically necessary diagnostic genetic testing)

All charges

Maternity Care - continued on next page

46 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Maternity Care (cont.) FEP Blue Focus

•

Childbirth preparation, Lamaze, and other birthing/parenting classes

•

Breast pumps and milk storage bags except as stated on page 46

•

Breastfeeding supplies other than those contained in the breast pump kit

described on page 46 including clothing (e.g., nursing bras), baby bottles,

or items for personal comfort or convenience (e.g., nursing pads)

•

Tocolytic therapy and related services except as described on page 45

•

Maternity care for members not enrolled in the Service Benefit Plan

All charges

Family Planning FEP Blue Focus

A range of voluntary family planning services for women, limited to:

• Contraceptive counseling

• Diaphragms and contraceptive rings

• Injectable contraceptives

• Intrauterine devices (IUDs)

• Implantable contraceptives

• Tubal ligation or tubal occlusion/tubal blocking procedures only

Family planning services for men, limited to:

• Vasectomy

Notes:

• We also provide benefits for professional services associated with tubal

ligation/occlusion/blocking procedures, vasectomy, and with the fitting,

insertion, or removal of the contraceptives as shown on the previous page.

• When billed by a facility, such as the outpatient department of a hospital,

we provide benefits as shown here, according to the contracting status of

the facility.

Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

• Oral and transdermal contraceptives

Note: We waive your cost-share for generic oral and transdermal

contraceptives when you purchase them at a Preferred retail pharmacy; see

Section 5(f) page 95.

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Reversal of voluntary surgical sterilization

•

Contraceptive devices not described above

•

Over-the-counter (OTC) contraceptives, except as described in Section 5(f)

All charges

Reproductive Services FEP Blue Focus

Diagnosis of infertility, limited to:

• Diagnostic services

• Laboratory tests

• Diagnostic tests

• Agents, drugs, and/or supplies administered or obtained in connection with

your care

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: When care is provided by a Non-preferred

laboratory and/or radiologist, as stated on page 18

for an exception, you pay:

Reproductive Services - continued on next page

47 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Reproductive Services (cont.) FEP Blue Focus

Note: See Section 5(a) for covered labs, diagnostic tests, and X-rays. Continued from previous page:

• Participating laboratories or radiologists: 30% of

the Plan allowance (deductible applies)

• Non-participating laboratories or radiologists:

30% of the Plan allowance, plus any difference

between our allowance and the billed amount

(deductible applies)

Not covered: The services listed below are not covered as treatments for

infertility or as alternatives to conventional conception:

•

Assisted reproductive technology (ART) and assisted insemination

procedures, including but not limited to:

Artificial insemination (AI)

In vitro fertilization (IVF)

Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote

intrafallopian transfer (ZIFT)

Intravaginal insemination (IVI)

Intracervical insemination (ICI)

Intracytoplasmic sperm injection (ICSI)

Intrauterine insemination (IUI)

•

Services, procedures, and/or supplies that are related to ART and assisted

insemination procedures

•

Cryopreservation or storage of sperm (sperm banking), eggs, or embryos

•

Preimplantation diagnosis, testing, and/or screening, including the testing

or screening of eggs, sperm, or embryos

•

Drugs used in conjunction with ART and assisted insemination procedures

•

Drugs to treat infertility

•

Services, supplies, or drugs provided to individuals not enrolled in this Plan

All charges

Allergy Care FEP Blue Focus

• Allergy testing

• Allergy treatment

• Allergy injections

• Sublingual allergy desensitization drugs as licensed by the U.S. FDA

• Preparation of each multi-dose vial of antigen

• Agents, drugs, and/or supplies administered or obtained in connection with

your care

Note: See page 39 for applicable office visit copayment.

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: When care is provided by a Non-preferred

laboratory and/or radiologist, as stated on page 18

for an exception, you pay:

• Participating laboratories or radiologists: 30% of

the Plan allowance (deductible applies)

• Non-participating laboratories or radiologists:

30% of the Plan allowance, plus any difference

between our allowance and the billed

amount (deductible applies)

Not covered: Provocative food testing All charges

48 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Treatment Therapies FEP Blue Focus

Outpatient treatment therapies:

• Chemotherapy and radiation therapy

Note: We cover high-dose chemotherapy and/or radiation therapy in

connection with bone marrow transplants, and drugs or medications to

stimulate or mobilize stem cells for transplant procedures, only for those

conditions listed as covered under

Organ/Tissue Transplants

in Section 5

(b). See also,

Other services

under

You need prior Plan approval for certain

services

in Section 3 (pages 19-22).

• Intensity-modulated radiation therapy (IMRT)*

Note: You must get prior approval for IMRT related to cancers, except

head, neck, breast, prostate, or anal cancer. Please refer to page 20 for

more information.

• Renal dialysis – Hemodialysis and peritoneal dialysis

• Intravenous (IV)/infusion therapy – Home IV or infusion therapy

Note: Home nursing visits (skilled) associated with Home IV/infusion

therapy are covered as shown under

Home Health Services

on page 54.

• Outpatient cardiac rehabilitation

• Pulmonary rehabilitation therapy

• Applied behavior analysis (ABA)* for the treatment of an autism spectrum

disorder limited to 200 hours per person, per calendar year (see prior

approval requirements on page 19)

• Auto-immune infusion medications: Remicade, Renflexis or Inflectra

• Agents, drugs, and/or supplies administered or obtained in connection with

your care

Notes:

• See Section 5(c) for our payment levels for treatment therapies billed for by

the outpatient department of a hospital.

• See page 55 for our coverage of osteopathic and chiropractic manipulative

treatment.

*Prior approval required

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Inpatient treatment therapies:

• Chemotherapy and radiation therapy

Note: We cover high-dose chemotherapy and/or radiation therapy in

connection with bone marrow transplants, and drugs or medications to

stimulate or mobilize stem cells for transplant procedures, only for those

conditions listed as covered under

Organ/Tissue Transplants

in Section 5

(b). See also,

Other services

under

You need prior Plan approval for certain

services

in Section 3 (pages 19-22).

• Renal dialysis – Hemodialysis and peritoneal dialysis

• Pharmacotherapy (medication management) (See Section 5(c) for our

coverage of drugs administered in connection with these treatment

therapies.)

• Applied behavior analysis (ABA)* for the treatment of an autism spectrum

disorder (see prior approval requirements on page 19)

*Prior approval required

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

49 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Physical Therapy, Occupational Therapy, Speech Therapy, and

Cognitive Rehabilitation Therapy

FEP Blue Focus

Outpatient treatment therapies, subject to visit limits:

• Physical therapy, occupational therapy, and speech therapy:

- Benefits are limited to 25 visits per person, per calendar year for

physical, occupational, or speech therapy, or a combination of all three;

regardless of the provider or facility billing for the services

• Cognitive rehabilitation therapy, limited to 25 visits per calendar year,

regardless of the provider billing the service

Preferred: $25 copayment per visit (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

Notes:

• You pay 30% of the Plan allowance (deductible

applies) for agents, drugs, and/or supplies

administered or obtained in connection with

your care. (See page 128 for more information

about “agents.”)

• See Section 5(c) for our payment levels for

rehabilitative therapies billed for by the

outpatient department of a hospital.

Not covered:

•

Recreational or educational therapy, and any related diagnostic testing

except as provided by a hospital as part of a covered inpatient stay

•

Maintenance or palliative rehabilitative therapy

•

Exercise programs

•

Hippotherapy/Equine therapy

•

Massage therapy

All charges

Hearing Services FEP Blue Focus

Visits related to the covered hearing services listed below Preferred: $10 copayment (no deductible) per visit

up to a combined total of 10 visits per calendar

year (benefits combined with visits in Section 5(a)

page 39)

Preferred provider, visits after the 10

visit: 30%

of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: You pay 30% of the Plan allowance

(deductible applies) for agents, drugs, and/or

supplies administered or obtained in connection

with your care. (See page 128 for more

information about “agents.”)

Hearing tests related to illness or injury Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Routine hearing tests (except as indicated on page 44 )

•

Hearing aids, including bone-anchored hearing aids, accessories or supplies

(including remote controls and warranty packages) and all associated

services

All charges

Hearing Services - continued on next page

50 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Hearing Services (cont.) FEP Blue Focus

•

Hearing aid exams All charges

Vision Services (Testing, Treatment, and Supplies) FEP Blue Focus

Eye examinations or visits related to a specific medical condition. Preferred: $10 copayment (no deductible) per visit

up to a combined total of 10 visits per calendar

year (benefits combined with visits in Section 5(a)

page 39)

Preferred provider, visits after the 10

visit: 30%

of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: You pay 30% of the Plan allowance

(deductible applies) for agents, drugs, and/or

supplies administered or obtained in connection

with your care. (See page 128 for more

information about “agents.”)

Diagnostic testing and treatment, such as:

• Nonsurgical treatment for amblyopia and strabismus, for children from

birth through age 21

• Lab, X-ray, and other diagnostic tests performed or ordered by your

provider.

• Refraction, only when the refraction is performed to determine the

prescription for the one pair of eyeglasses, replacement lenses, or contact

lenses provided per incident as described below.

Note: See Section 5(b),

Surgical Procedures

, for coverage for surgical

treatment of amblyopia and strabismus.

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Benefits are limited to one pair of eyeglasses, replacement lenses, or contact

lenses per incident prescribed:

• To correct an impairment directly caused by a single instance of accidental

ocular injury or intraocular surgery;

• If the condition can be corrected by surgery, but surgery is not an

appropriate option due to age or medical condition;

• For the nonsurgical treatment for amblyopia and strabismus, for children

from birth through age 21

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Eyeglasses, contact lenses, routine eye examinations, or vision testing for

the prescribing or fitting of eyeglasses or contact lenses, except as

described above

•

Deluxe eyeglass frames or lens features for eyeglasses or contact lenses

such as special coating, polarization, UV treatment, etc.

•

Multifocal, accommodating, toric, or other premium intraocular lenses

(IOLs) including Crystalens, ReStor, and ReZoom

•

Eye exercises, visual training, or orthoptics, except for nonsurgical

treatment of amblyopia and strabismus as described above

•

LASIK, INTACS, radial keratotomy, and other refractive surgical services

All charges

Vision Services (Testing, Treatment, and Supplies) - continued on next page

51 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Vision Services (Testing, Treatment, and Supplies) (cont.) FEP Blue Focus

•

Refractions, including those performed during an eye examination related

to a specific medical condition, except as described above

All charges

Foot Care FEP Blue Focus

Routine foot care when you are under active treatment for a metabolic or

peripheral vascular disease, such as diabetes

Notes:

• For corresponding office visits, see page 39.

• See below,

Orthopedic and Prosthetic Devices

, for information on podiatric

shoe inserts.

• See page 57, Section 5(b), for our coverage for surgical procedures.

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Routine foot care, such as cutting, trimming, or removal of corns, calluses,

or the free edge of toenails, and similar routine treatment of conditions of

the foot, except as stated above

All charges

Orthopedic and Prosthetic Devices FEP Blue Focus

Orthopedic braces and prosthetic appliances such as:

• Artificial limbs and eyes

• Functional foot orthotics when prescribed by a physician

• Rigid devices attached to the foot or a brace, or placed in a shoe

• Replacement, repair, and adjustment of covered devices

• Following a mastectomy, breast prostheses and surgical bras, including

necessary replacements

• Surgically implanted penile prostheses limited to treatment of erectile

dysfunction or as part of an approved plan for gender reassignment surgery

• Surgical implants

Note: A prosthetic appliance is a device that is surgically inserted or

physically attached to the body to restore a bodily function or replace a

physical portion of the body.

We provide hospital benefits for internal prosthetic devices, such as artificial

joints, pacemakers, cochlear implants, and surgically implanted breast

implants following mastectomy; see Section 5(c) for payment information.

Insertion of the device is paid as surgery; see Section 5(b).

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Shoes (including diabetic shoes)

•

Over-the-counter orthotics

•

Arch supports

•

Heel pads and heel cups

•

Wigs (including cranial prostheses)

•

Hearing aids, including bone anchored hearing aids, accessories or supplies

(including remote controls and warranty packages) and all associated

services

All charges

52 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Durable Medical Equipment (DME) FEP Blue Focus

Durable medical equipment (DME) is equipment and supplies that are:

1. Prescribed by your attending physician (i.e., the physician who is treating

your illness or injury);

2. Medically necessary;

3. Primarily and customarily used only for a medical purpose;

4. Generally useful only to a person with an illness or injury;

5. Designed for prolonged use; and

6. Used to serve a specific therapeutic purpose in the treatment of an illness or

injury.

We cover rental or purchase of durable medical equipment, at our option,

including repair and adjustment. Covered items include:

• Home dialysis equipment

• Oxygen equipment

• Hospital beds

• Wheelchairs

• Crutches

• Walkers

• Continuous passive motion (CPM) devices

• Dynamic orthotic cranioplasty (DOC) devices

• Insulin pumps

• Other items that we determine to be DME, such as compression stockings

• Specialty DME* to include:

- Specialty hospital beds

- Deluxe wheelchairs, power wheelchairs and mobility devices including

scooters and related supplies.

Note: We cover DME at Preferred benefit levels only when you use a

Preferred DME provider. Preferred physicians, facilities, and pharmacies are

not necessarily Preferred DME providers.

*Prior approval required

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

• Speech-generating devices, limited to $625 per calendar year Any amount over $625 per year (no deductible)

Not covered:

•

Exercise and bathroom equipment

•

Vehicle modifications, replacements, or upgrades

•

Home modifications, upgrades, or additions

•

Lifts, such as seat, chair, or van lifts

•

Car seats

•

Diabetic supplies , except as described in Section 5(f) or when Medicare

Part B is primary

•

Air conditioners, humidifiers, dehumidifiers, and purifiers

•

Breast pumps, except as described on page 46

All charges

Durable Medical Equipment (DME) - continued on next page

53 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Durable Medical Equipment (DME) (cont.) FEP Blue Focus

•

Communications equipment, devices, and aids (including computer

equipment) such as “story boards” or other communication aids to assist

communication-impaired individuals (except for speech-generating devices

as listed above)

•

Equipment for cosmetic purposes

•

Topical Hyperbaric Oxygen Therapy (THBO)

•

Charges associated with separate or extended warranties

All charges

Medical Supplies FEP Blue Focus

Covered medical supplies include:

• Medical foods and nutritional supplements when administered by catheter

or nasogastric tubes

Note: See page 131 for the definition of medical foods.

• Ostomy and catheter supplies

• Oxygen

Note: When billed by a skilled nursing facility, nursing home, or extended

care facility, we pay benefits as shown here for oxygen, according to the

contracting status of the facility. See page 77 for outpatient services

received while in a skilled nursing facility.

• Blood and blood plasma, except when donated or replaced, and blood

plasma expanders

Note: We cover medical supplies at Preferred benefit levels only when you

use a Preferred medical supply provider. Preferred physicians, facilities, and

pharmacies are not necessarily Preferred medical supply providers.

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Infant formulas used as a substitute for breastfeeding

•

Diabetic supplies , except as described in Section 5(f) or when Medicare

Part B is primary

•

Medical foods administered orally, except as described in Section 5(f)

All charges

Home Health Services FEP Blue Focus

Home nursing care (skilled) for two hours per day limited to 10 visits when:

• A registered nurse (R.N.) or licensed practical nurse (L.P.N.) provides the

services; and

• A physician orders the care.

Preferred: $25 copayment per visit (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: You pay 30% of the Plan allowance

(deductible applies) for agents, drugs, and/or

supplies administered or obtained in connection

with your care. (See page 128 for more

information about “agents.”)

Not covered:

•

Nursing care requested by, or for the convenience of, the patient or the

patient’s family

•

Services primarily for bathing, feeding, exercising, moving the patient,

homemaking, giving medication, or acting as a companion or sitter

All charges

Home Health Services - continued on next page

54 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

FEP Blue Focus

Benefit Description You Pay

Home Health Services (cont.) FEP Blue Focus

•

Services provided by a nurse, nursing assistant, health aide, or other

similarly licensed or unlicensed person that are billed by a skilled nursing

facility, extended care facility, or nursing home

•

Private duty nursing

All charges

Alternative/Manipulative Treatment FEP Blue Focus

Benefits for manipulative treatment and acupuncture are subject to a

combined limit of 10 visits per person per calendar year

• Acupuncture is covered when performed and billed by a healthcare

provider who is licensed or certified to perform acupuncture by the state

where the services are provided, and who is acting within the scope of that

license or certification. See page 16 for more information.

Note: See page 68 for our coverage of acupuncture when provided as

anesthesia for covered surgery.

Note: See page 45 for our coverage of acupuncture when provided as

anesthesia for covered maternity care.

• Manipulative treatment limited to:

- Osteopathic manipulative treatment to any body region

- Chiropractic spinal and/or extraspinal manipulative treatment

See Section 5(c), page 75, for facility benefits.

Preferred: $25 copayment per visit (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: You pay 30% of the Plan allowance

(deductible applies) for agents, drugs, and/or

supplies administered or obtained in connection

with your care. (See page 128 for more

information about “agents.”)

Not covered:

•

Biofeedback

•

Self-care or self-help training

All charges

Educational Classes and Programs FEP Blue Focus

• Smoking and tobacco cessation treatment including:

- Counseling for smoking and tobacco use cessation

- Smoking and tobacco cessation classes

Note: See Section 5(f) for our coverage of smoking and tobacco

cessation drugs.

Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

• Diabetic education

Note: See pages 39, 41 and 44 for our coverage of nutritional counseling

services that are not part of a diabetic education program.

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Marital, family, educational, or other counseling or training services, or

applied behavior analysis (ABA) , when performed as part of an educational

class or program

•

Premenstrual syndrome (PMS), lactation (except as described on page 46 ),

headache, eating disorder (except as described on page 39 ), and other

educational clinics

•

Recreational or educational therapy, and any related diagnostic testing

except as provided by a hospital as part of a covered inpatient stay

•

Services performed or billed by a school or halfway house or a member of

its staff

All charges

55 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(a)

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other

Healthcare Professionals

FEP Blue Focus

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure

and are payable only when we determine they are medically necessary.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how cost-sharing

works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age

65 or over.

•We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will

find that some benefits are listed in more than one Section of the brochure. This is because how they are paid

depends on what type of provider bills for the service.

•The services listed in this Section are for the charges billed by a physician or other healthcare professional

for your surgical care. See Section 5(c) for charges associated with a facility (i.e., hospital, surgical center,

etc.).

•Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drugs

when obtained from a covered provider other than a pharmacy under the pharmacy benefit. You must use a

Preferred pharmacy, thereafter. This benefit limitation does not apply if you have primary Medicare Part B

coverage. See page 93 for information about specialty drug fills from a Preferred pharmacy. Medications

restricted under this benefit are available on our FEP Blue Focus Specialty Drug List. Visit www.fepblue.org/

specialtypharmacy or call us at 888-346-3731.

•YOU MUST GET PRIOR APPROVAL for services such as the following: surgery for morbid obesity;

surgical correction of congenital anomalies; and oral maxillofacial surgeries/surgery on the jaw,

cheeks, lips, tongue, roof and floor of the mouth, and related procedures.

•YOU MUST GET PRIOR APPROVAL for all organ transplant surgical procedures (except kidney

and corneal transplants); and if your surgical procedure requires an inpatient admission, YOU MUST

GET PRECERTIFICATION. Please refer to the prior approval and precertification information

shown in Section 3 to be sure which services require prior approval or precertification.

•YOU MUST GET PRIOR APPROVAL for gender reassignment surgery. Prior to any gender

reassignment surgery, your provider must submit a treatment plan including all surgeries planned and

the estimated date each will be performed. A new prior approval must be obtained if the treatment

plan is approved and your provider later modifies the plan (including changes to the procedures to be

performed or the anticipated dates for the procedures). See page 20 and page 60 for additional

information. If your surgical procedure requires an inpatient admission, YOU MUST ALSO GET

PRECERTIFICATION of the inpatient care.

•YOU MUST GET PRIOR APPROVAL FOR CERTAIN PROCEDURES; FAILURE TO DO SO

WILL RESULT IN A $100 PENALTY. Please refer to Section 3, pages 19-22 for the complete list of

services which require prior approval.

•When multiple surgical procedures that add time or complexity to patient care are performed during the same

operative session, the Local Plan determines our allowance for the combination of multiple, bilateral, or

incidental surgical procedures. Generally, we will allow a reduced amount for procedures other than the

primary procedure.

•We do not pay extra for “incidental” procedures (those that do not add time or complexity to patient care).

•When unusual circumstances require the removal of casts or sutures by a physician other than the one

who applied them, the Local Plan may determine that a separate allowance is payable.

•The calendar year deductible is: $500 per person, ($1,000 per Self Plus One or Self and Family

enrollment). We state whether or not the calendar year deductible applies for each benefit listed in this

section.

56 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

•You must use Preferred providers in order to receive benefits. See below and page 18 for the exceptions

to this requirement.

•We provide benefits at Preferred benefit levels for services provided in Preferred facilities by Non-preferred

radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room

physicians, and assistant surgeons (including assistant surgeons in a physician’s office). You may be

responsible for any difference between our payment and the billed amount. See page 29, NSA, for

information on when you are not responsible for this difference.

Benefit Description You Pay

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Surgical Procedures FEP Blue Focus

A comprehensive range of services, such as:

• Operative procedures

• Assistant surgeons/surgical assistance if required because of the complexity of

the surgical procedures

• Treatment of fractures and dislocations, including casting

• Normal pre- and post-operative care by the surgeon

• Correction of amblyopia and strabismus

• Colonoscopy, with or without biopsy

Note: Preventive care benefits apply to the professional charges for your first

covered colonoscopy of the calendar year (see page 42). We provide benefits

as described here for subsequent colonoscopy procedures performed by a

professional provider in the same year.

• Endoscopic procedures

• Injections

• Biopsy procedures

• Removal of tumors and cysts

• Correction of congenital anomalies (see

Reconstructive Surgery

on page 59)

• Treatment of burns

• Male circumcision

• Insertion of internal prosthetic devices. See Section 5(a),

Orthopedic and

Prosthetic Devices

, and “Other hospital services and supplies” in Section

5(c),

Inpatient Hospital

, for our coverage for the device.

Preferred: 30% of the Plan allowance

(deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Procedures to treat morbid obesity – a condition in which an individual has a

Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or

more with one or more co-morbidities; eligible members must be age 18 or over

and the procedure must be performed at a facility designated as a Blue

Distinction Center for Comprehensive Bariatric Surgery.

• Benefits are available only for the following procedures:

- Roux-en-Y

- Gastric bypass

- Laparoscopic adjustable gastric banding

- Sleeve gastrectomy

- Biliopancreatic bypass with duodenal switch

When performed in a Blue Distinction Center

for Comprehensive Bariatric Surgery: 30% of

the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Note: Your provider will document the place of

service when filing your claim for the

procedure(s). Please contact the provider if you

have any questions about the place of the

service.

Surgical Procedures - continued on next page

57 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Benefit Description You Pay

Surgical Procedures (cont.) FEP Blue Focus

Notes:

• Benefits for the surgical treatment of morbid obesity are subject to the

requirements listed below.

• When the procedures are performed during an inpatient admission,

precertification is also required, see page 19 for more information.

• Prior approval is required for surgery for morbid obesity. For more

information about prior approval, please refer to page 20.

Requirements for surgical treatment of morbid obesity:

• Benefits for the surgical treatment of morbid obesity, performed on an

inpatient or outpatient basis, are subject to the pre-surgical requirements listed

below. The member must meet all requirements.

- Diagnosis of morbid obesity (as defined on page 57) for a period of 1 year

prior to surgery

- Participation in a medically supervised weight loss program, including

nutritional counseling, for at least 3 months prior to the date of surgery.

(Note: Benefits are not available for commercial weight loss programs; see

pages 41 and 44 for our coverage of nutritional counseling services.)

- Pre-operative nutritional assessment and nutritional counseling about pre-

and post-operative nutrition, eating, and exercise

- Evidence that attempts at weight loss in the 1-year period prior to surgery

have been ineffective

- Psychological clearance of the member’s ability to understand and adhere

to the pre- and post-operative program, based on a psychological

assessment performed by a licensed professional mental health practitioner

(see page 86 for our payment levels for mental health services)

- Member has not smoked in the 6 months prior to surgery

- Member has not been treated for substance use disorder for 1 year prior to

surgery and there is no evidence of substance use disorder during the 1-year

period prior to surgery

• Benefits for subsequent surgery for morbid obesity, performed on an inpatient

or outpatient basis, are subject to the following additional pre-surgical

requirements:

- All criteria listed above for the initial procedure must be met again, except

when the subsequent surgery is necessary to treat a complication from the

prior morbid obesity surgery.

- Previous surgery for morbid obesity was at least 2 years prior to repeat

procedure

- Weight loss from the initial procedure was less than 50% of the member’s

excess body weight at the time of the initial procedure

- Member complied with previously prescribed post-operative nutrition and

exercise program

- Claims for the surgical treatment of morbid obesity must include

documentation from the member’s provider(s) that all pre-surgical

requirements have been met

See previous page

Surgical Procedures - continued on next page

58 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Benefit Description You Pay

Surgical Procedures (cont.) FEP Blue Focus

Notes:

• When multiple surgical procedures that add time or complexity to patient care

are performed during the same operative session, the Local Plan determines

our allowance for the combination of multiple, bilateral, or incidental surgical

procedures. Generally, we will allow a reduced amount for procedures other

than the primary procedure.

• We do not pay extra for “incidental” procedures (those that do not add time or

complexity to patient care).

• When unusual circumstances require the removal of casts or sutures by a

physician other than the one who applied them, the Local Plan may determine

that a separate allowance is payable.

See previous page

Not covered:

•

Reversal of voluntary sterilization

•

Services of a standby physician

•

Routine surgical treatment of conditions of the foot (See Section 5(a),

Foot

care

•

Cosmetic surgery

•

LASIK, INTACS, radial keratotomy, and other refractive surgery

•

Surgeries related to sexual inadequacy (except surgical placement of penile

prostheses to treat erectile dysfunction and gender reassignment surgeries

specifically listed as covered)

•

Reversal of gender reassignment surgery

•

Surgical procedures for the treatment of morbid obesity when performed

outside a Blue Distinction Center

All charges

Reconstructive Surgery FEP Blue Focus

Reconstructive surgical procedures, limited to:

• Surgery to correct a functional defect

• Surgery to correct a congenital anomaly (See Section 10, page 129, for

definition.)

• Treatment to restore the mouth to a pre-cancer state

• All stages of breast reconstruction surgery following a mastectomy, such as:

- Surgery to produce a symmetrical appearance of the patient’s breasts

- Treatment of any physical complications, such as lymphedemas

Notes:

• Internal breast prostheses are paid as orthopedic and prosthetic devices;

see Section 5(a). See Section 5(c) when billed by a facility.

• If you need a mastectomy, you may choose to have the procedure

performed on an inpatient basis and remain in the hospital up to 48 hours

after the procedure.

• Surgery for placement of penile prostheses to treat erectile dysfunction

Preferred: 30% of the Plan allowance

(deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Reconstructive Surgery - continued on next page

59 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Benefit Description You Pay

Reconstructive Surgery (cont.) FEP Blue Focus

• Gender reassignment surgical benefits are limited to the following:

- For female to male surgery: mastectomy (including nipple reconstruction),

hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty,

phalloplasty, urethroplasty, scrotoplasty, electrolysis (hair removal at the

covered operative site), and placement of testicular and erectile prosthesis

- For male to female surgery: penectomy, orchiectomy, vaginoplasty,

clitoroplasty, labiaplasty, and electrolysis (hair removal at the covered

operative site)

Notes:

• Prior approval is required for gender reassignment surgery. For more

information about prior approval, please refer to page 20.

• Benefits for gender reassignment surgery are limited to once per covered

procedure, per lifetime. Benefits are not available for repeat or revision

procedures when benefits were provided for the initial procedure. Benefits are

not available for gender reassignment surgery for any condition other than

gender dysphoria.

• Gender reassignment surgery on an inpatient or outpatient basis is subject to

the pre-surgical requirements listed below. The member must meet all

requirements.

- Prior approval is obtained

- Member must be at least 18 years of age at the time prior approval is

requested and the treatment plan is submitted

- Diagnosis of gender dysphoria by a qualified healthcare professional

• New gender identity has been present for at least 24 continuous months

• Member has a strong desire to be rid of primary and/or secondary sex

characteristics because of a marked incongruence with the member’s

identified gender

• Member’s gender dysphoria is not a symptom of another mental disorder

or chromosomal abnormality

• Gender dysphoria causes clinical distress or impairment in social,

occupational, or other important areas of functioning

- Member must meet the following criteria:

• Living 12 months of continuous, full time, real life experience in the

desired gender (including place of employment, family, social and

community activities)

• 12 months of continuous hormone therapy appropriate to the member’s

gender identity (not required for mastectomy)

• Two referral letters from qualified mental health professionals – one must

be from a psychotherapist who has treated the member for a minimum of

12 months. Letters must document: diagnosis of persistent and chronic

gender dysphoria; any existing co-morbid conditions are stable; member

is prepared to undergo surgery and understands all practical aspects of

the planned surgery (one referral letter required for mastectomy)

• If medical or mental health concerns are present, they are being

optimally managed and are reasonably well-controlled

Preferred: 30% of the Plan allowance

(deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Reconstructive Surgery - continued on next page

60 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Benefit Description You Pay

Reconstructive Surgery (cont.) FEP Blue Focus

Not covered:

•

Cosmetic surgery – any operative procedure or any portion of a procedure

performed primarily to improve physical appearance through change in bodily

form – unless required for a congenital anomaly or to restore or correct a part

of the body that has been altered as a result of accidental injury, disease, or

surgery (does not include anomalies related to the teeth or structures

supporting the teeth)

•

Surgeries related to sexual dysfunction or sexual inadequacy (except surgical

placement of penile prostheses to treat erectile dysfunction and gender

reassignment surgeries specifically listed as covered)

•

Reversal of gender reassignment surgery

All charges

Oral and Maxillofacial Surgery FEP Blue Focus

Oral surgical procedures when prior approved are limited to:

• Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor

of mouth when pathological examination is necessary

• Surgery needed to correct accidental injuries (see

Definitions

, page 128) to

jaws, cheeks, lips, tongue, roof and floor of mouth

• Excision of exostoses of jaws and hard palate

• Incision and drainage of abscesses and cellulitis

• Incision and surgical treatment of accessory sinuses, salivary glands, or ducts

• Reduction of dislocations and excision of temporomandibular joints

• Removal of impacted teeth

Notes:

• See page 20 for information regarding prior approval.

• Prior approval is required for oral/maxillofacial surgery, except when

related to an accidental injury and provided within 72 hours of the accident.

For more information regarding the prior approval see page 19.

• Call us at the customer service phone number on the back of your ID card to

verify that your provider is Preferred for the type of care (e.g., oral surgery)

you are scheduled to receive.

Preferred: 30% of the Plan allowance

(deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered:

•

Oral implants and transplants except for those required to treat accidental

injuries as specifically described above and in Section 5(g)

•

Surgical procedures that involve the teeth or their supporting structures (such

as the periodontal membrane, gingiva, and alveolar bone ), except for those

required to treat accidental injuries as specifically described above and in

Section 5(g)

•

Surgical procedures involving dental implants or preparation of the mouth for

the fitting or the continued use of dentures, except for those required to treat

accidental injuries as specifically described above and in Section 5(g)

•

Orthodontic care before, during, or after surgery, except for orthodontia

associated with surgery to correct accidental injuries as specifically described

above and in Section 5(g)

All charges

61 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Organ/Tissue Transplants

Prior approval requirements:

For the transplants listed below, you must obtain prior approval (see pages 19-22) from the Local Plan, for the procedure and

precertification (see page 19) for the facility admission. Prior approval is not required for kidney transplants or for transplants of

corneal tissue. Additional benefit requirements apply for the coverage of certain transplants, see pages 66-67.

•Blood or marrow stem cell transplant procedures

Note: See pages 64-65 for additional requirements that apply to blood or marrow stem cell transplants that are covered only as

part of a clinical trial.

•Autologous pancreas islet cell transplant

•Heart-lung transplant

•Heart transplant

•Implantation of an artificial heart as a bridge to transplant or destination therapy

•Intestinal transplants (small intestine with or without other organs)

•Liver transplant

•Lung (single, double, or lobar) transplant

•Pancreas transplant

•Combination liver-kidney transplant

•Combination pancreas-kidney transplant

Covered organ/tissue transplants are listed on page 66. Benefits are subject to medical necessity and experimental/investigational

review, and to the prior approval requirements shown above.

In addition, benefits are only available for some transplants (and covered related services) when performed in a Blue Distinction

Center or Medicare-Approved Transplant Program. Please see pages 65-66 for more information on the benefits available for the

services below. Benefits for implantation of an artificial heart as a bridge to transplant or destination therapy are only available when

the facility is designated as a Blue Distinction Center for heart transplants.

Must be performed in a Blue Distinction Center for Transplant:

•Blood or marrow stem cell transplants

•Heart transplants

•Liver transplants

•Adult single, double or lobar lung transplants

•Adult combination liver-kidney transplants

Must be performed in a Medicare-Approved Transplant Program:

•Heart-lung transplants

•Kidney

•Intestinal

•Adult pancreas transplants

•Pediatric lung transplants

•Adult combination pancreas-kidney transplants

62 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Must be performed in a Preferred hospital by a Preferred provider:

•Autologous pancreas islet cell transplants

•Corneal tissue transplants

•Pediatric pancreas transplants

•Pediatric combination liver-kidney transplants

•Pediatric combination pancreas-kidney transplants

Note: Refer to pages 19-22 for information about precertification of inpatient care.

Blood or marrow stem cell transplants are covered as shown below and on pages 64-65. Benefits are limited to the stages of the

diagnoses listed.

Physicians consider many features to determine how diseases will respond to different types of treatments. Some of the features

measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and

how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to

treatment without transplant and which diseases may respond to transplant. For the diagnoses listed on the following pages, the

medical necessity limitation is considered satisfied if the patient meets the staging description.

Notes:

•Coverage for the blood or marrow stem cell transplants described below and on the top of page 65 includes benefits for those

transplants performed in an approved clinical trial to treat any of the conditions listed when prior approval is obtained. Refer to the

bottom of page 64 and the top of page 65 for information about blood or marrow stem cell transplants covered only in clinical trials

and the additional requirements that apply.

•See pages 121-122 for our coverage of other costs associated with clinical trials.

The following transplants are only covered for the diagnosis indicated for the transplant procedure.

Benefits for Allogeneic blood or marrow stem cell transplants are only available for the diagnoses as indicated below:

•Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia

•Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with poor response to therapy, short time to progression,

transformed disease, or high risk disease

•Chronic myelogenous leukemia

•Hemoglobinopathy (i.e., sickle cell anemia, thalassemia major)

•High-risk neuroblastoma

•Hodgkin’s lymphoma

•Infantile malignant osteopetrosis

•Inherited metabolic disorders (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy, Hurler’s syndrome

and Maroteaux-Lamy syndrome variants)

•Marrow failure (i.e., severe or very severe aplastic anemia, Fanconi’s anemia, paroxysmal nocturnal hemoglobinuria (PNH), pure

red cell aplasia, congenital thrombocytopenia)

•MDS/MPN (e.g., chronic myelomonocytic leukemia (CMML))

•Myelodysplasia/myelodysplastic syndromes (MDS)

•Myeloproliferative neoplasms (MPN) (e.g., polycythemia vera, essential thrombocythemia, primary myelofibrosis)

•Non-Hodgkin’s lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)

•Paroxysmal Nocturnal Hemoglobinuria

•Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)

63 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

•Plasma cell disorders (e.g., multiple myeloma, amyloidosis, polyneuropathy, organomegaly, endocrinopathy, monoclonal

gammopathy, and skin changes (POEMS) syndrome)

•Primary immunodeficiencies (e.g., severe combined immunodeficiency, Wiskott-Aldrich syndrome, hemophagocytic

lymphohistiocytosis, X-linked lymphoproliferative syndrome, Kostmann’s syndrome, leukocyte adhesion deficiencies)

•Severe combined immunodeficiency

•Severe or very severe aplastic anemia

•Sickle cell anemia

•X-linked lymphoproliferative syndrome

Notes:

•See page 62 for the prior approval and facility transplant program requirements that apply to blood or marrow stem cell transplants.

•Refer to pages 64-65 for information about blood or marrow stem cell transplants covered only in clinical trials.

Benefits for Autologous blood or marrow stem cell transplants are only available for the diagnoses as indicated below:

•Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia

•Central nervous system (CNS) embryonal tumors (e.g., atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumors

(PNETs), medulloblastoma, pineoblastoma, ependymoblastoma)

•Ewing’s sarcoma

•Germ cell tumors (e.g., testicular germ cell tumors)

•High-risk neuroblastoma

•Hodgkin’s lymphoma

•Non-Hodgkin’s lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)

•Plasma cell disorders (e.g., multiple myeloma, amyloidosis, polyneuropathy, organomegaly, endocrinopathy, monoclonal

gammopathy, and skin changes (POEMS) syndrome)

•Scleroderma

Notes:

•See page 62 for the prior approval and facility transplant program requirements that apply to blood or marrow stem cell transplants.

•See below and page 65 for information about blood or marrow stem cell transplants covered only in clinical trials.

Clinical Trials:

Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries to

answer scientific questions and to find better ways to prevent, diagnose, or treat patients. A clinical trial has possible benefits as well

as risks. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the

trial, and the beginning and end points of the trial. Information regarding clinical trials is available at www.cancer.gov/about-cancer/

treatment/clinical-trials.

Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials

or there may not be any trials available in a Blue Distinction Center for Transplants to treat your condition at the time you seek to be

included in a clinical trial. If your physician has recommended you participate in a clinical trial, we encourage you to contact the Case

Management Department at your Local Plan for assistance.

Transplants that may be eligible for clinical trials:

Benefits for Blood or marrow stem cell transplants are available for the diagnoses below, only when performed as part of a

clinical trial that meets the transplant program prior approval criteria described on page 62 and the requirements listed below, when

a clinical trial for the diagnosis is available in a Blue Distinction Center; and you meet the criteria for inclusion in the clinical trial:

64 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

•Allogeneic blood or marrow stem cell transplants for:

- Breast cancer

- Colon cancer

- Epidermolysis bullosa

- Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)

- Ovarian cancer

- Prostate cancer

- Renal cell carcinoma

- Retinoblastoma

- Rhabdomyosarcoma

- Sarcoma

- Wilm’s tumor

•Allogeneic blood or marrow stem cell transplants or autologous blood or marrow stem cell transplants for:

- Autoimmune disease (limited to: multiple sclerosis, scleroderma, systemic lupus erythematosus and chronic inflammatory

demyelinating polyneuropathy)

•Autologous blood or marrow stem cell transplants for:

- Autoimmune disease (limited to: multiple sclerosis, systemic lupus erythematosus and chronic inflammatory demyelinating

polyneuropathy)

•Autologous blood or marrow stem cell transplants for:

- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)

- Chronic myelogenous leukemia

- Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)

- Retinoblastoma

- Rhabdomyosarcoma

- Wilm’s tumor and other childhood kidney cancers

Note: A transplant clinical trial may not be available for your condition. If you or your provider are considering a clinical trial, please

contact us at the phone number on the back of your ID card for assistance in determining if a covered clinical trial is available in a

covered facility.

If a non-randomized clinical trial for a blood or marrow stem cell transplant listed above meeting the requirements shown on pages

64-65 is not available in a covered facility near you, we will arrange for the transplant to be provided at an approved transplant

program, if a clinical trial is available and you meet the inclusion criteria to participate in the clinical trial.

Benefits for Blood or marrow stem cell transplants are only available for the diagnoses as indicated above only when performed

at a Blue Distinction Center for Transplants (see page 17) as part of a clinical trial that meets the requirements listed below:

•You must contact us at the customer service phone number listed on the back of your ID card to obtain prior approval (see pages

19-22); and

•The patient must be properly and lawfully registered in the clinical trial, meeting all the eligibility requirements of the trial; and

•For the transplant procedures listed above, the clinical trial must be reviewed and approved by the Institutional Review Board for

the Blue Distinction Center for Transplant program where the procedure is to be performed.

See page 121-122 for our coverage of other costs associated with clinical trials.

65 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Benefit Description You Pay

Organ/Tissue Transplants FEP Blue Focus

The following transplants must be performed at a Blue Distinction Centers for

Transplants (see page 17 for more information):

• Blood or marrow stem cell transplants (adult and pediatric) listed on pages 63-64

• Heart transplant (adult and pediatric)

- Implantation of an artificial heart as a bridge to transplant or destination therapy

(when performed in a Blue Distinction Center for Heart Transplants)

• Liver transplant (adult and pediatric)

• Lung:

- For members with end-stage cystic fibrosis, benefits for lung transplantation are

limited to double lung transplants

• Combination liver-kidney transplant

• Single, double, or lobar lung transplant (adult)

Note: For covered related transplant services, see pages 66 and 67.

When performed in a Blue Distinction

Centers for Transplants: 30% of the Plan

allowance (deductible applies)

All other providers (Participating/Non-

participating): You pay all charges

Note: Your provider will document the place

of service when filing your claim for the

procedure(s). Please contact the provider if

you have any questions about the place of

the service.

The following transplants are not available in a Blue Distinction Centers for

Transplants

and must be performed at a Preferred facility with a Medicare-

Approved transplant program, if one is available (see below):

• Autologous pancreas islet cell transplant (as an adjunct to total or near total

pancreatectomy) only for patients with chronic pancreatitis

• Corneal tissue transplant

• Heart-lung transplant

• Intestinal transplants (small intestine) and the small intestine with the liver or

small intestine with multiple organs such as the liver, stomach, and pancreas

• Kidney transplant

• Pancreas transplant

• Combination liver-kidney transplant (pediatric)

• Combination pancreas-kidney transplant

• Single, double, or lobar lung transplant (pediatric)

Notes:

• Organ transplants that are not available in a Blue Distinction Center for

Transplants must be performed in a facility with a Medicare-Approved Transplant

Program for the type of transplant anticipated. Transplants involving more than

one organ must be performed in a facility that offers a Medicare-Approved

Transplant Program for each organ transplanted. Contact your local Plan for

Medicare’s approved transplant programs.

• If Medicare does not offer an approved program for a certain type of organ

transplant procedure, this requirement does not apply and you may use any

Preferred facility that performs the procedure. If Medicare offers an approved

program for an anticipated organ transplant, but your facility is not approved by

Medicare for the procedure, please contact your Local Plan at the customer

service phone number appearing on the back of your ID card.

Preferred: 30% of the Plan allowance

(deductible applies)

Non-preferred (Participating/Non-

participating): You pay all charges

Note: Your provider will document the place

of service when filing your claim for the

procedure(s). Please contact the provider if

you have any questions about the place of

the service.

Organ/Tissue Transplants - continued on next page

66 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Benefit Description You Pay

Organ/Tissue Transplants (cont.) FEP Blue Focus

Related transplant services:

• Extraction or reinfusion of blood or marrow stem cells as part of a covered

allogeneic or autologous transplant

• Harvesting, immediate preservation, and storage of stem cells when the

autologous blood or marrow stem cell transplant has been scheduled or is

anticipated to be scheduled within an appropriate time frame for patients

diagnosed at the time of harvesting with one of the conditions listed on pages

63-65

Note: Benefits are available for charges related to fees for storage of harvested

autologous blood or marrow stem cells related to a covered autologous stem cell

transplant that has been scheduled or is anticipated to be scheduled within an

appropriate time frame. No benefits are available for any charges related to fees

for long term storage of stem cells.

• Collection, processing, storage and distribution of cord blood only when provided

as part of a blood or marrow stem cell transplant scheduled or anticipated to be

scheduled within an appropriate time frame for patients diagnosed with one of the

conditions listed on pages 63-65

• Covered medical and hospital expenses of the donor, when we cover the recipient

• Covered services or supplies provided to the recipient

• Donor screening tests for up to three non-full sibling (such as unrelated) potential

donors, for any full sibling potential donors, and for the actual donor used for

transplant

Note: See Section 5(a) for coverage for related services, such as chemotherapy and/

or radiation therapy and drugs administered to stimulate or mobilize stem cells for

covered transplant procedures.

Preferred: 30% of the Plan allowance

(deductible applies)

Non-preferred (Participating/Non-

participating): You pay all charges

Travel benefits:

Members who receive covered care at a Blue Distinction Center for Transplants

for one of the transplants listed on page 65 can be reimbursed for incurred travel

costs related to the transplant, subject to the criteria and limitations described here.

You must obtain prior approval for travel benefits (see page 22).

We reimburse costs for transportation (air,

rail, bus, and/or taxi) and lodging if you live

50 miles or more from the facility, up to a

maximum of $5,000 per transplant for the

member and companions. Reimbursement is

subject to IRS regulations.

Not covered:

•

Any transplant not listed as covered and t ransplants for any diagnosis not listed as

covered

•

Transplants performed in a facility other than the type of facility required for the

particular transplant (see page 66 regarding transplants that must be performed in

a Blue Distinction Center for Transplants and page 66 for transplants that must be

performed in a Medicare-Approved Transplant Program

•

Donor screening tests and donor search expenses, including associated travel

expenses, except as defined above

•

Implants of artificial organs, including those implanted as a bridge to transplant

and/or as destination therapy, other than medically necessary implantation of an

artificial heart as described on page 66

•

Implantation of an artificial heart in a facility not designated as a Blue Distinction

Center for Heart Transplant

•

Allogeneic pancreas islet cell transplantation

All charges

Organ/Tissue Transplants - continued on next page

67 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

FEP Blue Focus

Benefit Description You Pay

Organ/Tissue Transplants (cont.) FEP Blue Focus

•

Travel costs related to covered transplants performed at facilities other than Blue

Distinction Centers for Transplants; travel costs incurred when prior approval has

not been obtained; travel costs outside those allowed by IRS regulations, such as

food-related expenses

All charges

Anesthesia FEP Blue Focus

Anesthesia services consist of administration by injection or inhalation of a drug or

other anesthetic agent (including acupuncture) to obtain muscular relaxation, loss of

sensation, or loss of consciousness.

Anesthesia (including acupuncture) for covered medical or surgical services when

requested by the attending physician and performed by:

• A certified registered nurse anesthetist (CRNA), or

• A physician other than the physician (or the assistant) performing the covered

medical or surgical procedure

Professional services provided in:

• Hospital (inpatient)

• Hospital outpatient department

• Skilled nursing facility

• Ambulatory surgical center

• Residential treatment center

• Office

Notes:

• Anesthesia acupuncture services do not accumulate toward the member’s annual

maximum.

• See Section 5(c) for our payment levels for anesthesia services billed by a facility.

Preferred: 30% of the Plan allowance

(deductible applies)

Non-preferred (Participating/Non-

participating): You pay all charges

68 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(b)

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance

Services

FEP Blue Focus

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure

and are payable only when we determine they are medically necessary.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how cost-sharing

works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age

65 or over.

•YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL

RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3 to be sure

which services require precertification.

•YOU MUST GET PRECERTIFICATION FOR RESIDENTIAL TREATMENT CENTER STAYS.

Please refer to the precertification information listed in Section 3.

•Note: Observation services are billed as outpatient facility care. Benefits for observation services are

provided at the outpatient facility benefit levels described on page 74. See page 131-132 for more

information about these types of services.

•YOU MUST GET PRIOR APPROVAL for services such as the following: surgery for morbid obesity;

surgical correction of congenital anomalies; and oral maxillofacial surgeries/surgery on the jaw,

cheeks, lips, tongue, roof and floor of the mouth, and related procedures.

•YOU MUST GET PRIOR APPROVAL for gender reassignment surgery. See page 20 for prior

approval and page 60 for the surgical benefit.

•When PRIOR APPROVAL IS REQUIRED for a surgical procedure and the surgery is performed on an

inpatient basis, YOU MUST ALSO GET PRECERTIFICATION for the inpatient admission.

•You should be aware that some Non-preferred (non-PPO) professional providers may provide services in

Preferred (PPO) facilities.

•You must use Preferred providers in order to receive benefits. See page 18 for the exceptions to this

requirement.

- You are responsible for the applicable cost-sharing amounts for care performed and billed by Preferred

professional providers in the outpatient department of a Preferred hospital.

•We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will

find that some benefits are listed in more than one Section of the brochure. This is because how they are paid

depends on what type of provider or facility bills for the service.

•The services listed in this Section are for the charges billed by the facility (i.e., hospital or surgical center) or

ambulance service, for your inpatient or outpatient surgery or care. Any costs associated with the professional

charge (i.e., physicians, etc.) are listed in Sections 5(a) or 5(b).

•The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family

enrollment). We state whether or not the calendar year deductible applies for each benefit listed in this

section.

•Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drugs

when obtained from a covered provider other than a pharmacy under the pharmacy benefit. You must use a

Preferred pharmacy, thereafter. This benefit limitation does not apply if you have primary Medicare Part B

coverage. See page 93 for information about specialty drug fills from a Preferred pharmacy. Medications

restricted under this benefit are available on our FEP Blue Focus Specialty Drug List. Visit www.fepblue.org/

specialtypharmacy or call us at 888-346-3731.

69 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Inpatient Hospital FEP Blue Focus

Room and board, such as:

• Semiprivate or intensive care accommodations

• General nursing care

• Meals and special diets

Note: We cover a private room only when you must be isolated to prevent

contagion, when your isolation is required by law, or when a hospital only has

private rooms.

Other inpatient hospital services and supplies, such as:

• Operating, recovery, and other treatment rooms

• Prescribed drugs and medications

• Diagnostic studies, radiology services, laboratory tests, and pathology

services

• Administration of blood or blood plasma

• Dressings, splints, casts, and sterile tray services

• Internal prosthetic devices

• Other medical supplies and equipment, including oxygen

• Anesthetics and anesthesia services

• Take-home items

• Pre-admission testing recognized as part of the hospital admissions process

• Nutritional counseling

• Acute inpatient rehabilitation

Note: Observation services are billed as outpatient facility care. As a result,

benefits for observation services are provided at the outpatient facility benefit

levels described on page 74. See pages 131-132 for more information about

these types of services.

Here are some things to keep in mind:

• If you need to stay longer in the hospital than initially planned, we will

cover an extended stay if it is medically necessary. However, you must

precertify the extended stay. See page 26 for information on requesting

additional days.

• We pay inpatient hospital benefits for an admission in connection with the

treatment of children up to age 22 with severe dental caries. We cover

hospitalization for other types of dental procedures only when a non-dental

physical impairment exists that makes hospitalization necessary to

safeguard the health of the patient. We provide benefits for dental

procedures as shown in Section 5(g).

Notes:

• See pages 76 and 87 for inpatient residential treatment center.

• See pages 71-73 for other covered maternity services.

• For inpatient care received overseas, refer to Section 5(i) page 107.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

You pay all charges

Inpatient Hospital - continued on next page

70 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Inpatient Hospital (cont.) FEP Blue Focus

Not covered:

•

Admission to noncovered facilities, such as nursing homes, extended care/

skilled nursing facilities, schools, or residential treatment centers (except as

described on pages 76 and 87)

•

Personal comfort items, such as guest meals and beds, phone, television,

beauty and barber services

•

Private duty nursing

•

Facility room and board expenses when, in our judgment, an admission or

portion of an admission is:

Custodial or long term care (see

Definitions

)

Convalescent care or a rest cure

Domiciliary care provided because care in the home is not available or is

unsuitable

•

Care that is not medically necessary, such as:

When services did not require the acute hospital inpatient (overnight)

setting but could have been provided safely and adequately in a

physician’s office, the outpatient department of a hospital, or some other

setting, without adversely affecting your condition or the quality of

medical care you receive.

Admissions for, or consisting primarily of, observation and/or evaluation

that could have been provided safely and adequately in some other

setting (such as a physician’s office)

Admissions primarily for diagnostic studies, radiology services,

laboratory tests, or pathology services that could have been provided

safely and adequately in some other setting (such as the outpatient

department of a hospital or a physician’s office)

Note: If we determine that an inpatient admission is one of the types listed

above, we will not provide benefits for inpatient room and board or inpatient

physician care. However, we will provide benefits for covered services or

supplies other than room and board and inpatient physician care at the level

that we would have paid if they had been provided in some other setting.

Benefits are limited to care provided by covered facility providers (see pages

17-18).

All charges

Maternity – Facility FEP Blue Focus

We encourage you to notify us of your pregnancy during the first trimester,

see page 24.

Maternity (obstetrical) care including related conditions resulting in childbirth

or miscarriage, such as:

• Inpatient facility care,

• Care at birthing facilities, and

• Services you receive on an outpatient basis

• Tocolytic therapy and related services when provided on an inpatient basis

during a covered hospital admission or during a covered observation stay

Preferred facilities: $1,500 copayment per

pregnancy (no deductible)

Non-preferred facilities (Member/Non-member):

You pay all charges

Maternity – Facility - continued on next page

71 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Maternity – Facility (cont.) FEP Blue Focus

Notes:

• We cover up to 4 visits per year in full to treat depression associated with

pregnancy (i.e., depression during pregnancy, postpartum depression, or

both) when you use a Preferred provider. See page 45.

• Preventive care benefits apply to the screening of pregnant members for

HIV, syphilis and unhealthy alcohol use/substance use when billed by a

facility.

Room and board, such as:

• Semiprivate or intensive care accommodations

• General nursing care

• Meals and special diets

Other inpatient hospital services and supplies, such as:

• Administration of blood or blood plasma

• Anesthetics and anesthesia services

• Breastfeeding education

• Covered medical supplies and equipment, including oxygen

• Delivery, operating, recovery, and other treatment rooms

• Diagnostic studies, radiology services, laboratory tests, and pathology

services

• Dressings and sterile tray services

• Nutritional counseling

• Prescribed drugs and medications

• Take-home items

Here are some things to keep in mind:

• You do not need to precertify your delivery; see page 26 for other

circumstances, such as extended stays for you or your newborn.

• You may remain in the hospital up to 48 hours after a vaginal delivery and

96 hours after a cesarean delivery. We will cover an extended stay if

medically necessary.

• We cover routine nursery care of the newborn when performed during the

covered portion of the mother’s maternity stay and billed by the facility. We

cover other care of a newborn who requires professional services or non-

routine treatment, only if we cover the newborn under a Self Plus One or

Self and Family enrollment. Surgical benefits apply to circumcision if

billed by a professional provider for a male newborn.

• When a newborn requires definitive treatment during or after the mother’s

confinement, the newborn is considered a patient in his or her own right.

Regular medical or surgical benefits apply rather than maternity benefits.

• See page 57 for our payment levels for circumcision.

• Note: For inpatient care received overseas, refer to Section 5(i), page 107.

See previous page

Maternity – Facility - continued on next page

72 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Maternity – Facility (cont.) FEP Blue Focus

Not covered:

•

Breast pumps and milk storage bags except as stated on page 46

•

Breastfeeding supplies other than those contained in the breast pump kit

described on page 46 including clothing (e.g., nursing bras), baby bottles,

or items for personal comfort or convenience (e.g., nursing pads)

•

Childbirth preparation, Lamaze, and other birthing/parenting classes

•

Doula, birth companion, and similar supporter

•

Genetic testing/screening of the baby’s father (see page 40 for our coverage

of medically necessary diagnostic genetic testing)

•

Genetic testing not specifically stated as covered on page 43

•

Maternity care for members not enrolled in this Plan

•

Personal comfort items, such as guest meals and beds, phone, television,

beauty and barber services

•

Private duty nursing

•

Procedures, services, drugs, and supplies related to abortions except when

the life of the mother would be endangered if the fetus were carried to term

or when the pregnancy is the result of an act of rape or incest

•

Tocolytic therapy and related services except as described on page 71

All charges

Outpatient Hospital or Ambulatory Surgical Center FEP Blue Focus

Outpatient surgical and treatment services performed and billed by a

facility, such as:

• Operating, recovery, and other treatment rooms

• Anesthetics and anesthesia services

• Pre-surgical testing performed within one business day of the covered

surgical services

• Chemotherapy and radiation therapy

• Colonoscopy, with or without biopsy

Note: Preventive care benefits apply to the facility charges for your first

covered colonoscopy of the calendar year (see page 42). We provide

diagnostic benefits for services related to subsequent colonoscopy

procedures in the same year.

• Intravenous (IV)/infusion therapy

• Renal dialysis

• Visits to the outpatient department of a hospital for non-emergency

treatment services

• Diabetic education

• Administration of blood, blood plasma, and other biologicals

• Blood and blood plasma, if not donated or replaced, and other biologicals

• Dressings, splints, casts, and sterile tray services

• Facility supplies for hemophilia home care

• Other medical supplies, including oxygen

• Surgical implants

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

You pay all charges

Outpatient Hospital or Ambulatory Surgical Center - continued on next page

73 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Outpatient Hospital or Ambulatory Surgical Center (cont.) FEP Blue Focus

• Cardiac rehabilitation

• Observation services

Note: All outpatient services billed by the facility during the time you are

receiving observation services are included in the cost-share amounts

shown here. Please refer to Section 5(a) for services billed by professional

providers during an observation stay and page 70 for information about

benefits for inpatient admissions.

• Pulmonary rehabilitation

• Hospital-based clinic visits

• Outpatient hospital services and supplies related to:

- Treatment of children up to age 22 with severe dental caries.

- Dental procedures only when a non-dental physical impairment exists

that makes the hospital setting necessary to safeguard the health of the

patient. See Section 5(g),

Dental Benefits

, page 102.

Notes:

• See pages 81-84 for our payment levels for care related to a medical

emergency or accidental injury.

• See pages 47 for our coverage of family planning services.

• See page 76 for outpatient drugs, medical devices, and durable medical

equipment billed for by a facility.

• See page 71 for maternity care provided in an outpatient facility.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

You pay all charges

Outpatient diagnostic testing performed and billed by a facility, such as:

• Angiographies

• Bone density tests

• CT scans*/MRIs*/PET scans*

• Genetic testing*

Note: We cover specialized diagnostic genetic testing billed for by a

facility, such as the outpatient department of a hospital, as shown here. See

page 43 for coverage criteria and limitations.

• Nuclear medicine

• Sleep studies

• Cardiovascular monitoring

• EEGs

• Ultrasounds

• Neurological testing

• X-rays (including set-up of portable X-ray equipment)

• EKGs

• Laboratory tests and pathology services

Note: For outpatient facility care related to maternity, including outpatient

care at birthing facilities, see

Maternity – Facility

, page 71 in this Section.

*Prior approval is required.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

• Member: 30% of the Plan allowance (deductible

applies)

• Non-member: 30% of the Plan allowance

(deductible applies), plus any difference

between our allowance and the billed amount

Outpatient Hospital or Ambulatory Surgical Center - continued on next page

74 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Outpatient Hospital or Ambulatory Surgical Center (cont.) FEP Blue Focus

Outpatient treatment and therapy services performed and billed by a

facility, limited to:

• Cognitive rehabilitation therapy limited to 25 visits per person per calendar

year

• Physical therapy, occupational therapy, and speech therapy limited to 25

visits per person, per calendar year for physical, occupational, or speech

therapy, or a combination of all three.

• Manipulative treatment and acupuncture services, limited to a combined 10

visits per person.

Notes:

- We provide benefits for manipulative treatment and acupuncture services

as described on page 55.

- See page 68 for our coverage of acupuncture when provided as

anesthesia for covered surgery.

- See page 72 for our coverage of acupuncture when provided as

anesthesia for covered maternity care.

Note: The limitations listed above are a combined total regardless of the type

of covered provider or facility billing for the services.

Preferred facilities: $25 copayment per visit (no

deductible)

Non-preferred facilities (Member/Non-member):

You pay all charges

Note: You pay 30% of the Plan allowance

(deductible applies) for supplies or drugs

administered or obtained in connection with your

care. (See page 128 for more information about

“agents.”)

Outpatient treatment services performed and billed by a facility, are limited

to:

• Outpatient applied behavior analysis* (ABA) for an autism spectrum

disorder performed and billed by a facility limited to 200 hours per person,

per calendar year.

Note: The limitations listed is a combined total regardless of the type of

covered provider or facility billing for the services.

*Prior approval is required, see pages 19-22 for prior approval

requirements.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

You pay all charges

Outpatient adult preventive care performed and billed by a facility, limited

to:

• Visits/exams for preventive care, screening procedures, and routine

immunizations described on pages 41-43

• Cancer screenings listed on pages 41-42 and ultrasound screening for

abdominal aortic aneurysm

Notes:

• See page 43 for our coverage requirements for preventive BRCA testing.

• See page 44 for our payment levels for covered preventive care services for

children billed for by facilities and performed on an outpatient basis.

Preferred facilities: Nothing (no deductible)

Non-preferred facilities (Member/Non-Member):

Nothing (no deductible) for cancer screenings and

ultrasound screening for abdominal aortic

aneurysm

Note: Benefits are not available for routine adult

physical examinations, associated laboratory tests,

colonoscopies, or routine immunizations

performed at Non-preferred (Member/Non-

member) facilities.

Outpatient Hospital or Ambulatory Surgical Center - continued on next page

75 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Outpatient Hospital or Ambulatory Surgical Center (cont.) FEP Blue Focus

Outpatient drugs, medical devices, and durable medical equipment billed

for by a facility, such as:

• Prescribed drugs and medications

Note: Certain self-injectable drugs are covered only when dispensed by a

pharmacy under the pharmacy benefit. These drugs will be covered once

per lifetime per therapeutic category of drugs when dispensed by a non-

pharmacy-benefit provider. This benefit limitation does not apply if you

have primary Medicare Part B coverage. See page 93 for information about

specialty drug fills from a Preferred pharmacy.

• Orthopedic and prosthetic devices

• Durable medical equipment

• Surgical implants

• Oral and transdermal contraceptives

Note: We waive your cost-share for generic oral and transdermal

contraceptives when you purchase them at a Preferred retail pharmacy; see

Section 5(f) page 95.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

You pay all charges

Residential Treatment Center FEP Blue Focus

Inpatient Residential Treatment Center:

Precertification prior to admission is required.

A preliminary treatment plan and discharge plan must be developed and

agreed to by the member, provider (residential treatment center (RTC)), and

case manager in the Local Plan where the RTC is located prior to admission.

We cover up to a combined total (medical and mental health and substance

use disorder) of 30 days per calendar year of inpatient care provided and

billed by an RTC for members enrolled and participating in case management

through the Local Plan, when the care is medically necessary for treatment of

a medical, mental health, and/or substance use disorder:

• Room and board, such as semiprivate room, nursing care, meals, special

diets, ancillary charges, and covered therapy services when billed by the

facility (see page 86 for services billed by professional providers).

Notes:

• For inpatient care received overseas, refer to Section 5(i), page 107.

• For outpatient residential treatment center services, see page 87.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

You pay all charges

Not covered services, such as:

•

Biofeedback

•

Custodial or long term care (see

Definitions

)

•

Domiciliary care provided because care in the home is not available or is

unsuitable

•

Educational therapy or educational classes

•

Equine/hippotherapy provided during the approved stay

•

Recreational therapy

•

Respite care

All charges

Residential Treatment Center - continued on next page

76 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Residential Treatment Center (cont.) FEP Blue Focus

•

Outdoor residential programs

•

Outward Bound programs

•

Personal comfort items, such as guest meals and beds, phone, television,

beauty and barber service

•

Services provided outside of the provider’s licensure/scope of practice

Note: Residential treatment center benefits are not available for facilities

licensed as skilled nursing facilities, group home, halfway house or similar

type facilities.

All charges

Extended Care Benefits/Skilled Nursing Care Facility Benefits FEP Blue Focus

There are no benefits for admissions to an extended care or skilled

nursing facility.

All charges

Benefits are available for the following covered services when provided as

outpatient services and billed by a skilled nursing facility:

• Oxygen

Note: See Section 5(f) for benefits for prescription drugs.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

You pay all charges

Benefits are available for the following covered professional services when

provided as outpatient services and billed by a skilled nursing facility:

• Cognitive rehabilitation therapy, limited to 25 visits per calendar year,

regardless of the provider billing the service

• Physical therapy, occupational therapy, or speech therapy or a combination

of all three (regardless of the provider or facility billing for the services)

limited to 25 visits per person, per calendar year

Preferred: $25 copayment per visit (no deductible)

Non-preferred (Member/Non-member): You pay

all charges

Note: You pay 30% of the Plan allowance

(deductible applies) for agents, drugs, and/or

supplies administered or obtained in connection

with your care. (See page 128 for more

information about “agents.”)

Not covered:

•

Inpatient room and board billed by a skilled nursing facility

•

Phone; television; personal comfort items, such as guest meals and beds,

beauty and barber services, recreational outings/trips, stretcher or

wheelchair transportation; non-emergent ambulance transport that is

requested beyond the nearest facility adequately equipped to treat the

member’s condition, by patient or physician for continuity of care or other

reason; custodial or long term care (see

Definitions

), and domiciliary care

provided because care in the home is not available or is unsuitable.

All charges

Hospice Care FEP Blue Focus

Hospice care is an integrated set of services and supplies designed to provide

palliative and supportive care to members with a projected life expectancy of

six months or less due to a terminal medical condition, as certified by the

member’s primary care provider or specialist.

See pages 78-79

Hospice Care - continued on next page

77 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Hospice Care (cont.) FEP Blue Focus

Pre-Hospice Enrollment Benefits

Prior approval is not required.

Before home hospice care begins, members may be evaluated by a physician

to determine if home hospice care is appropriate. We provide benefits for pre-

enrollment visits when provided by a physician who is employed by the home

hospice agency and when billed by the agency employing the physician. The

pre-enrollment visit includes services such as:

• Evaluating the member’s need for pain and/or symptom management; and

• Counseling regarding hospice and other care options

Prior approval from the Local Plan is required for all hospice services.

Our prior approval decision will be based on the medical necessity of the

hospice treatment plan and the clinical information provided to us by the

primary care provider (or specialist) and the hospice provider. We may also

request information from other providers who have treated the member. All

hospice services must be billed by the approved hospice agency. You are

responsible for making sure the hospice care provider has received prior

approval from the Local Plan (see pages 19-22 for instructions).

Please check with your Local Plan, and/or visit www.fepblue.org/provider to

use our National Doctor & Hospital Finder, for listings of Preferred hospice

providers.

Note: If Medicare Part A is the primary payor for the member’s hospice care,

prior approval is not required. However, our benefits will be limited to those

services listed in this Section.

Members with a terminal medical condition (or those acting on behalf of

the member) are encouraged to contact the Case Management

Department at their Local Plan for information about hospice services

and Preferred hospice providers.

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Covered services:

We provide benefits for the hospice services listed below when the services

have been included in an approved hospice treatment plan and are provided

by the home hospice program in which the member is enrolled:

• Advanced care planning (see Section 10, page 128)

• Dietary counseling

• Durable medical equipment rental

• Medical social services

• Medical supplies

• Nursing care

• Oxygen therapy

• Periodic physician visits

• Physical therapy, occupational therapy, and speech therapy related to the

terminal medical condition

• Prescription drugs and medications

• Services of home health aides (certified or licensed, if the state requires it,

and provided by the home hospice agency)

See page 79

Hospice Care - continued on next page

78 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Hospice Care (cont.) FEP Blue Focus

Traditional Home Hospice Care*

Periodic visits to the member’s home for the management of the terminal

medical condition and to provide limited patient care in the home. An episode

of care is one home hospice treatment plan per calendar year. See page 20 for

prior approval requirements.

*Prior approval is required

Preferred facilities: Nothing (no deductible)

Non-preferred facilities (Member/Non-member):

You pay all charges

Continuous Home Hospice Care*

Services provided in the home to members enrolled in home hospice during a

period of crisis, such as frequent medication adjustments to control symptoms

or to manage a significant change in the member’s condition, requiring a

minimum of 8 hours of care during each 24-hour period by a registered nurse

(R.N.) or licensed practical nurse (L.P.N.).

Note: Members must receive prior approval from the Local Plan for each

episode of continuous home hospice care (see page 20). An episode consists

of up to seven consecutive days of continuous care. The member must be

enrolled in a home hospice program in order to receive benefits for

subsequent continuous home hospice care and the services must be provided

by the home hospice program in which the member is enrolled.

*Prior approval is required

Preferred facilities: Nothing (no deductible)

Non-preferred facilities (Member/Non-member):

You pay all charges

Inpatient Hospice Care*

Benefits are available for inpatient hospice care when provided by a facility

that is licensed as an inpatient hospice facility and when:

• Inpatient services are necessary to control pain and/or manage the

member’s symptoms;

• Death is imminent; or

• Inpatient services are necessary to provide an interval of relief (respite) to

the caregiver

Note: Benefits are provided for up to 30 consecutive days in a facility

licensed as an inpatient hospice facility. The member does not have to be

enrolled in a home hospice care program to be eligible for the first inpatient

stay. However, the member must be enrolled in a home hospice care program

in order to receive benefits for subsequent inpatient stays.

*Prior approval is required

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

You pay all charges

Not covered:

•

Advanced care planning, except when provided as part of a covered

hospice care treatment plan (see page 78)

•

Homemaker services

•

Home hospice care (e.g., care given by a home health aide) that is provided

and billed for by other than the approved home hospice agency when the

same type of care is already being provided by the home hospice agency

All charges

79 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

FEP Blue Focus

Benefit Description You Pay

Ambulance FEP Blue Focus

Professional ambulance transport services to or from the nearest hospital

equipped to adequately treat your condition, when medically necessary, and:

• Associated with covered hospital inpatient care

• Related to medical emergency

• Associated with covered hospice care

Notes:

• We also cover medically necessary emergency care provided at the scene

when transport services are not required.

• Prior approval is required for all non-emergent air ambulance

transport.

30% of the Plan allowance (deductible applies)

Professional ambulance transport services to or from the nearest hospital

equipped to adequately treat your condition, when medically necessary, and

when related to accidental injury care for your accidental injury.

Notes:

• We also cover medically necessary emergency care provided at the scene

when transport services are not required.

• Prior approval is required for all non-emergent air ambulance transport.

Nothing (no deductible)

Note: These benefit levels apply only if you

receive care in connection with, and within 72

hours after, an accidental injury. For services

received after 72 hours, see above.

Medically necessary emergency ground, air and sea ambulance transport

services to the nearest hospital equipped to adequately treat your condition if

you travel outside the United States, Puerto Rico and the U.S. Virgin Islands

Note: If you are traveling overseas and need assistance with emergency

evacuation services to the nearest facility equipped to adequately treat your

condition, please contact the Overseas Assistance Center (provided by

GMMI) by calling 804-673-1678. See page 107 for more information.

30% of the Plan allowance (deductible applies)

Not covered:

•

Wheelchair van services and gurney van services

•

Ambulance and any other modes of transportation to or from services

including but not limited to physician appointments, dialysis, or diagnostic

tests not associated with covered inpatient hospital care

•

Ambulance transport that is requested, beyond the nearest facility

adequately equipped to treat the member’s condition, by patient or

physician for continuity of care or other reason

•

Commercial air flights

•

Repatriation from an international location back to the United States. See

definition of repatriation in Section 10. Members traveling overseas should

consider purchasing a travel insurance policy that covers repatriation to

your home country.

•

Costs associated with overseas air or sea transportation to other than the

closest hospital equipped to adequately treat your condition

All charges

80 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(c)

Section 5(d). Emergency Services/Accidents

FEP Blue Focus

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure

and are payable only when we determine they are medically necessary.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how cost-sharing

works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age

65 or over.

•You should be aware that some Non-preferred (non-PPO) professional providers may provide services in

Preferred (PPO) facilities.

•You must use Preferred providers in order to receive benefits, except in cases of medical emergency or

accidental injury. Refer to the guidelines appearing below for additional information.

•We provide benefits at Preferred benefit levels for emergency department services performed by both PPO

and non-PPO providers when their services are related to an accidental injury or medical emergency. The

Plan allowance for these services is determined by the contracting status of the provider. Note: For

information regarding the Plan allowance, see

Definitions

on pages 132-133. If services are performed by

non-PPO professional providers in a PPO facility, you will be responsible for your cost-share for those

services. For more information, see page 29, NSA.

•The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family

enrollment). We state whether or not the calendar year deductible applies for each benefit listed in this

section.

What is an accidental injury?

An accidental injury is an injury caused by an external force or element such as a blow or fall and which requires immediate medical

attention, including animal bites, and poisonings. (See Section 5(g) for dental care for accidental injury.)

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could

result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not

treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because

they are potentially life threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There

are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick

action.

You are encouraged to seek care from Preferred providers in cases of accidental injury or medical emergency. However, if you need

care immediately and cannot access a Preferred provider, we will provide benefits for the initial treatment provided in the emergency

room of any hospital – even if the hospital is not a Preferred facility. We will also provide benefits if you are admitted directly to the

hospital from the emergency room until your condition has been stabilized. In addition, we will provide benefits for emergency

ambulance transportation provided by Preferred or Non-preferred ambulance providers if the transport is due to a medical emergency

or accidental injury.

We provide emergency benefits when you have acute symptoms of sufficient severity – including severe pain – such that a prudent

layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical

attention to result in serious jeopardy to the person’s health, or with respect to a pregnant member, the health of the member and the

unborn child.

81 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(d)

FEP Blue Focus

Benefit Description You pay

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Accidental Injury FEP Blue Focus

When you receive care for your accidental injury within 72 hours of the

injury, we cover:

• Professional provider services in the emergency room, hospital outpatient

department, including professional care, diagnostic studies, radiology

services, laboratory tests, and pathology services, when billed by a

professional provider

• Outpatient hospital services and supplies, including professional provider

services, diagnostic studies, radiology services, laboratory tests, and

pathology services, when billed by the hospital

• Urgent care centers licensed as and permitted to provide emergency

services and supplies, including professional providers’ services, diagnostic

studies, radiology services, laboratory tests and pathology services, when

billed by the urgent care center provider

Notes:

• All follow-up care must be performed and billed for by Preferred providers

to be eligible for benefits.

• The urgent care center must be licensed and permitted to provide

emergency services in order to receive protections under the NSA. See

page 29 for more information.

• See Section 5(g) for dental benefits for accidental injury.

Preferred: Nothing (no deductible)

Participating: Nothing (no deductible)

Non-participating: Nothing (no deductible)

Non-preferred facilities (Member/Non-member):

• Member: Nothing (no deductible)

• Non-member: Nothing (no deductible)

Note: The benefits described above apply only if

you receive care in connection with, and within 72

hours after, an accidental injury. For services

received after 72 hours, regular benefits apply. See

Sections 5(a), 5(b), and 5(c) for the benefits we

provide.

Professional provider services in the providers office, including, diagnostic

studies, radiology services, laboratory tests, and pathology services, when

billed by a professional provider.

Preferred: Nothing (no deductible)

Participating: Nothing (no deductible)

Non-participating: Any difference between our

allowance and the billed amount (no deductible)

Note: The benefits described above apply only if

you receive care in connection with, and within 72

hours after, an accidental injury. For services

received after 72 hours, regular benefits apply. See

Sections 5(a), 5(b), and 5(c) for the benefits we

provide.

When you are admitted to the hospital within 72 hours of an accidental injury,

your inpatient admission and inpatient professional care you receive is

covered regardless of the hospital’s or professional provider’s network status.

Notes:

• See Section 5(a), page 39 for inpatient professional services.

• See Section 5(c) for services associated with an inpatient admission.

• All follow-up care must be performed and billed for by Preferred providers

to be eligible for coverage.

• See page 29 for your protections against balance billing from Non-

participating providers.

• For more information regarding non-participating provider exceptions, see

page 18.

30% of the Plan allowance (deductible applies)

Note: In certain circumstance you may be

responsible for any difference between our

allowance and the billed amount for care you

receive from Non-member facilities. See page 29

for more information on your protections against

balance billing from Non-participating providers.

Accidental Injury - continued on next page

82 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(d)

FEP Blue Focus

Benefit Description You pay

Accidental Injury (cont.) FEP Blue Focus

Urgent care centers, not licensed as or permitted to provide emergency

services and supplies, including professional providers’ services, diagnostic

studies, radiology services, laboratory tests and pathology services, when

billed by the provider.

Preferred urgent care center: Nothing (no

deductible)

Non-preferred (Participating and Non-

participating): You pay all charges

Not covered:

•

Oral surgery except as shown in Section 5(b)

•

Injury to the teeth while eating

•

Emergency room professional charges for shift differentials

All charges

Medical Emergency FEP Blue Focus

Outpatient medical or surgical services and supplies related to a medical

emergency to include:

• Professional provider services in the emergency room, including

professional care, diagnostic studies, radiology services, laboratory tests,

and pathology services, when billed by a professional provider

• Outpatient hospital emergency room services and supplies, including

professional provider services, diagnostic studies, radiology services,

laboratory tests, and pathology services, when billed by the hospital

Notes:

• All follow-up care must be performed and billed for by Preferred providers

to be eligible for benefits.

• If you are treated by a non-PPO professional provider in a PPO facility

your liability for the difference between our allowance and the billed

amount may be limited under the NSA. See page 29 for more information.

• We pay inpatient benefits if you are admitted as a result of a medical

emergency. See Section 5(c).

• Regular benefit levels apply to covered services provided in settings other

than the emergency room. See Section 5(c) for those benefits.

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred professional providers (Participating

and Non-participating):

• Participating: 30% of the Plan allowance

(deductible applies)

• Non-participating: 30% of the Plan allowance

(deductible applies)

Non-preferred facilities (Member/Non-member):

• Member: 30% of the Plan allowance (deductible

applies)

• Non-member: 30% of the Plan

allowance (deductible applies)

• Urgent care centers, licensed as and permitted to provide emergency

services and supplies, including professional providers’ services, diagnostic

studies, radiology services, laboratory tests and pathology services, when

billed by the provider regardless of the providers network status

Notes:

• The urgent care center must be licensed as and permitted to provide

emergency services in order to receive protections under the NSA. See

page 29 for more information.

• Benefits for crutches, splints, braces, etc. when billed by a provider other

than the urgent care center are stated in Section 5(a), page 53.

$25 copayment per visit (no deductible)

Medical Emergency - continued on next page

83 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(d)

FEP Blue Focus

Benefit Description You pay

Medical Emergency (cont.) FEP Blue Focus

• Urgent care centers, not licensed as or permitted to provide emergency

services and supplies, including professional providers’ services, diagnostic

studies, radiology services, laboratory tests and pathology services, when

billed by the provider

Note: Benefits for crutches, splints, braces, etc. when billed by a provider

other than the urgent care center are stated in Section 5(a), page 53.

Preferred urgent care center: $25 copayment per

visit (no deductible)

Non-preferred (Participating/Non-participating):

You pay all charges

Not covered: Emergency room professional charges for shift differentials All charges

Ambulance FEP Blue Focus

See page 80 for complete ambulance benefit and coverage information. See page 80

84 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(d)

Section 5(e). Mental Health and Substance Use Disorder Benefits

FEP Blue Focus

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure

and are payable only when we determine they are medically necessary.

•If you have an acute chronic and/or complex condition, you may be eligible to receive the services of a

professional case manager to assist in assessing, planning, and facilitating individualized treatment options

and care. For more information about our Case Management process, please refer to page 104. Contact us at

the phone number listed on the back of your ID card if you have any questions or would like to discuss your

healthcare needs.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how cost-sharing

works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age

65 or over.

•Every year, we conduct an analysis of the financial requirements and treatment limitations which apply to

this Plan’s mental health and substance use disorder benefits in compliance with the federal Mental Health

Parity and Addiction Equity Act (the Act), and the Act’s implementing regulations. Based on the results of

this analysis, we may suggest changes to program benefits to OPM. More information on the Act is available

on the following Federal Government websites:

https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html

https://www.dol.gov/ebsa/

https://www.samhsa.gov/health-financing/implementation-mental-health-parity-addiction-equity-act

•YOU MUST GET PRECERTIFICATION FOR HOSPITAL OR RESIDENTIAL TREATMENT

CENTER STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the

precertification information listed in Section 3.

•The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family enrollment).

We state whether or not the calendar year deductible applies for each benefit listed in this section.

•You must use Preferred providers in order to receive benefits. See page 18 for the exceptions to this

requirement.

•You should be aware that some Non-preferred (non-PPO) professional providers may provide services in

Preferred (PPO) facilities.

•There is a $10 visit copayment for each of the first 10 visits to a professional provider per calendar year. This

applies to a combined total for medical and mental health and substance use disorder conditions.

Benefit Description You Pay

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Professional Services FEP Blue Focus

We cover professional services by licensed professional mental health and

substance use disorder practitioners when acting within the scope of their

license.

Your cost-sharing responsibilities are no greater

than for other illnesses or conditions.

Professional Services - continued on next page

85 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(e)

FEP Blue Focus

Benefit Description You Pay

Professional Services (cont.) FEP Blue Focus

Services provided by licensed professional mental health and substance use

disorder practitioners when acting within the scope of their license

Outpatient professional services including:

• Individual psychotherapy

• Group psychotherapy

• Pharmacologic (medication) management

• Office visits

• Clinic visits

• Home visits

• Phone consultations and online medical evaluation and management

services (telemedicine)

Notes:

• We cover up to 4 visits per year in full to treat depression associated with

pregnancy under maternity benefits (i.e., depression during pregnancy,

postpartum depression, or both) when you use a Preferred provider. See

page 45.

• To locate a Preferred provider, visit www.fepblue.org/provider to use our

National Doctor & Hospital Finder, or contact your Local Plan at the

mental health and substance use disorder phone number on the back of your

ID card.

• See pages 55 and 98 for our coverage of smoking and tobacco cessation

treatment.

We cover outpatient mental health and substance use disorder services or

supplies provided and billed by residential treatment centers at the levels

shown here. Prior approval is required.

Preferred: $10 copayment (no deductible) per visit

up to a combined total of 10 visits per calendar

year (benefits combined with visits in Section 5(a),

page 39)

Preferred provider, visits after the 10

visit: 30%

of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating):

You pay all charges

Telehealth professional services for:

• Behavioral health counseling

• Substance use disorder counseling

Notes:

• Refer to Section 5(h),

Wellness and Other Special Features

, for information

on telehealth services and how to access our telehealth provider network.

• Copayments are waived for members with Medicare Part B primary.

Preferred Telehealth Provider: Nothing (no

deductible) for the first 2 visits per calendar year

for any covered telehealth service received

(benefits are combined with telehealth services

listed in Section 5(a), page 39)

$10 copayment per visit (no deductible) after the

visit

Non-preferred (Participating/Non-participating):

You pay all charges

Services provided by licensed professional mental health and substance use

disorder practitioners when acting within the scope of their license:

• Inpatient professional services

• Professional charges for facility-based intensive outpatient treatment

• Professional charges for outpatient diagnostic tests to include psychological

testing

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

86 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(e)

FEP Blue Focus

Benefit Description You Pay

Inpatient Hospital or Other Covered Facility FEP Blue Focus

Inpatient services to treat mental health and/or substance use disorders

provided and billed by a hospital or other covered facility (see below for

residential treatment center care) includes:

• Room and board, such as semiprivate or intensive accommodations,

general nursing care, meals and special diets, and other hospital services

• Diagnostic tests

Notes:

• Inpatient care to treat substance use disorders includes room and board and

ancillary charges for confinements in a hospital/treatment facility for

rehabilitative treatment of alcoholism or substance use disorder.

• You must get precertification of inpatient hospital stays; failure to do so

will result in a $500 penalty.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred (Member/Non-member) facilities:

You pay all charges

Residential Treatment Center FEP Blue Focus

Precertification prior to admission is required.

A preliminary treatment plan and discharge plan must be developed and

agreed to by the member, provider (residential treatment center (RTC)), and

case manager in the Local Plan where the RTC is located prior to admission

We cover up to a combined total (medical and mental health) of 30 days of

inpatient care provided and billed by an RTC for members enrolled and

participating in case management through the Local Plan, when the care is

medically necessary for treatment of a medical, mental health, and/or

substance use disorder:

• Room and board, such as semiprivate room, nursing care, meals, special

diets, ancillary charges, and covered therapy services when billed by the

facility (see page 86 for services billed by professional providers)

Notes:

• RTC benefits are not available for facilities licensed as a skilled nursing

facility, group home, halfway house, or similar type facility.

• Benefits are not available for noncovered services, including: respite care;

outdoor residential programs; services provided outside of the provider’s

scope of practice; recreational therapy; educational therapy; educational

classes; biofeedback; Outward Bound programs; hippotherapy/equine

therapy provided during the approved stay; personal comfort items, such as

guest meals and beds, phone, television, beauty and barber services;

custodial or long term care (see

Definitions

); and domiciliary care provided

because care in the home is not available or is unsuitable.

• For outpatient residential treatment center services, see next page.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred (Member/Non-member) facilities:

You pay all charges

87 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(e)

FEP Blue Focus

Benefit Description You Pay

Outpatient Hospital or Other Covered Facility FEP Blue Focus

Outpatient services provided and billed by a covered facility

• Diagnostic tests

• Group psychotherapy

• Individual psychotherapy

• Intensive outpatient treatment

• Partial hospitalization

• Pharmacologic (medication) management

• Psychological testing

Note: We cover outpatient mental health and substance use disorder services

or supplies provided and billed by residential treatment centers at the levels

shown here. Prior approval is required. Failure to obtain prior approval will

result in a $100.00 penalty. See page 19.

Preferred facilities: 30% of the Plan allowance

(deductible applies)

Non-preferred (Member/Non-member) facilities:

You pay all charges

Not covered:

•

Marital, family, educational, or other counseling or training services

•

Services performed by a noncovered provider

•

Testing for and treatment of learning disabilities and intellectual disability

•

Inpatient services performed or billed by residential treatment centers,

except as described on pages 76 and 87

•

Services performed or billed by schools, halfway houses, group homes or

members of their staffs

Note: We cover professional services as described on page 16 when they

are provided and billed by a covered professional provider acting within the

scope of their license.

•

Psychoanalysis or psychotherapy credited toward earning a degree or

furtherance of education or training regardless of diagnosis or symptoms

that may be present

•

Services performed or billed by residential therapeutic camps (e.g.,

wilderness camps, Outward Bound, etc.)

•

Light boxes

•

Custodial or long term care (see

Definitions

)

•

Costs associated with enabling or maintaining providers’ telehealth

(telemedicine) technologies, non-interactive telecommunication such as

email communications, or asynchronous store-and-forward telehealth

services

All charges

88 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(e)

Section 5(f). Prescription Drug Benefits

FEP Blue Focus

Important things you should keep in mind about these benefits:

•We cover prescription drugs and supplies, as described in the chart beginning on page 93.

•If there is no generic drug available, you must pay the brand-name cost-sharing amount when you receive a

brand-name drug.

•If there is a generic substitution available and you or your provider requests a brand-name drug, you will be

responsible for the applicable cost-share plus the difference in the costs of the brand-name and generic drugs.

•If the cost of your prescription is less than your cost-sharing amount, you pay only the cost of your

prescription.

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure

and are payable only when we determine they are medically necessary.

•Benefits for certain self-injectable (self-administered) drugs are provided only when they are dispensed by a

pharmacy under the pharmacy benefit. See page 93 for specialty drug fills from a Preferred pharmacy.

•Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are

covered only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or

ambulatory surgical center). See

Drugs From Other Sources

in this Section, page 100, for more information.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how cost-sharing

works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age

65 or over.

•Medication prices vary among different retail pharmacies and the Specialty Drug Pharmacy Program.

Review purchasing options for your prescriptions to get the best price. A drug cost tool is available at

www.fepblue.org or call:

- Retail Pharmacy Program: 800-624-5060, TTY: 800-624-5077

- Specialty Drug Pharmacy Program: 888-346-3731, TTY: 877-853-9549

•YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS AND SUPPLIES, and prior approval

must be renewed periodically. Prior approval is part of our Patient Safety and Quality Monitoring (PSQM)

program. Please refer to page 92 for more information about the PSQM program and to Section 3 for more

information about prior approval. Our prior approval process may include step therapy, which requires you to

use a generic and/or preferred medication(s) before a non-preferred medication is covered.

•During the course of the year, we may move a brand-name drug from Tier 2 (preferred brand-name, preferred

generic specialty and preferred brand-name specialty drugs) to noncovered if a generic equivalent or

biosimilar becomes available or if new safety concerns arise. If your drug is moved to noncovered, you pay

the full cost of the medication. Tier reassignments during the year are not considered benefit changes.

•A pharmacy restriction may be applied for clinically inappropriate use of prescription drugs and supplies.

•You must use Preferred FEP Blue Focus retail pharmacies or the Specialty Drug Pharmacy Program

in order to receive benefits. Our specialty drug pharmacy is a Preferred pharmacy.

•There is no calendar year deductible for the Retail Pharmacy Program or the Specialty Drug Pharmacy

Program.

•The FEP Blue Focus formulary contains a comprehensive list of drugs under all therapeutic categories with

two exceptions: some drugs, nutritional supplements and supplies are noncovered (see page 99); we may also

exclude certain U.S. FDA-approved drugs when multiple generic equivalents/alternative medications are

available. See page 91 for details.

•The Blue Cross and Blue Shield Service Benefit Plan’s FEP Blue Focus uses a closed formulary, see

page 90.

89 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

We will send each new enrollee an FEP Blue Focus identification card, which covers pharmacy and medical benefits.

There are important features you should be aware of. These include:

•Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or,

in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write

your prescriptions. See Section 5(i) for drugs purchased overseas.

•Where you can obtain them.

You must fill prescriptions only at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program, in order to receive

benefits. See page 134 for the definition of “specialty drugs.” For information about prescriptions obtained from an overseas retail

pharmacy, see page 108.

The Retail Pharmacy Program is administered by CVS Caremark. For a listing of Preferred retail pharmacies, call the Retail

Pharmacy Program at 800-624-5060, TTY: 800-624-5077, or visit our website, www.fepblue.org.

Note: If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the

drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section

7 for instructions on how to file prescription drug claims.

The Specialty Drug Pharmacy Program is administered by CVS Caremark.

Notes:

- The Specialty Drug Pharmacy Program will not fill your prescription until you have obtained prior approval. CVS Caremark, the

program administrator, will hold your prescription for up to 30 days. If prior approval is not obtained within 30 days, your

prescription will be returned to you along with a letter explaining the prior approval procedures.

- Preferred retail pharmacies may offer options for ordering prescription drugs online. Drugs ordered online may be delivered to

your home and these online orders are a part of the Retail Prescription Drug Program described on page 93.

- Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available

only through a Preferred retail pharmacy. See page 98 for information about your cost-share for specialty drugs purchased at a

Preferred retail pharmacy that are affected by these restrictions.

•What is covered.

We use a closed formulary.

If you purchase a drug that is not on the formulary, you will pay the full cost of that drug.

The FEP Blue Focus Formulary includes a list of preferred drugs that are safe, effective and appropriate for our members

and are available at lower costs than other drugs.

Some drugs, nutritional supplements, and supplies are not covered (see page 99); we may also exclude certain U.S. FDA-approved

drugs when multiple generic equivalents/alternative medications are available. If you purchase a drug, nutritional supplement, or

supply that is not covered, you will be responsible for the full cost of the item.

Notes:

- Before filling your prescription, please check the FEP Blue Focus Formulary drug list and tier assignment of the drug.

Other than changes resulting from new drugs or safety issues, the preferred drug list is updated periodically during the

year and not considered a benefit change.

90 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

- Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the tier

assignments for formulary drugs, we work with our Pharmacy and Medical Policy Committee, a group of physicians and

pharmacists who are not employees or agents of, nor have financial interest in, the Blue Cross and Blue Shield Service Benefit

Plan. The Committee meets quarterly to review new and existing drugs to assist us in our assessment. Drugs determined to be of

equal therapeutic value and similar safety and efficacy are then evaluated on the basis of cost. The Committee’s

recommendations, together with our evaluation of the relative cost of the drugs, determine the placement of formulary drugs on a

specific tier. Using lower cost preferred generic drugs will provide you with a high-quality, cost-effective prescription drug

benefit.

Your cooperation with our cost-saving efforts helps keep your premium affordable.

Our payment levels are generally categorized as:

Tier 1: Preferred generic drugs obtained at a Preferred retail pharmacy

Tier 2: Preferred brand-name drugs, preferred generic specialty drugs, and preferred brand-name specialty drugs obtained at a

Preferred retail pharmacy or through the Specialty Drug Pharmacy Program.

You can view the formulary on our website at www.fepblue.org or call 800-624-5060, TTY: 800-624-5077, for assistance. If you do

not find your drug on the formulary, or the preferred drug list, please call 800-624-5060. Changes to the formulary are not

considered benefit changes.

Any savings we receive on the cost of drugs purchased under this Plan from drug manufacturers are credited to the reserves held for

this Plan.

•Generic equivalents

Generic equivalent drugs have the same active ingredients as their brand-name equivalents. By filling your prescriptions (or those

of family members covered by the Plan) at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program, you

authorize the pharmacist to substitute any available Federally approved generic equivalent, unless you or your physician

specifically request a brand-name drug. However, if there is a generic substitution available and you or your provider requests a

brand-name drug, you will be responsible for the applicable cost-share plus the difference in the costs of the brand-name and

generic drugs. Keep in mind that FEP Blue Focus members must use Preferred pharmacies in order to receive benefits. See

page 130 for more information about generic alternatives and generic equivalents.

•Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your

prescription drug utilization, including the names of your prescribing physicians, to any treating physicians or dispensing

pharmacies.

•These are the dispensing limitations.

Subject to manufacturer packaging and your prescriber’s instructions, you may purchase either up to a 30-day supply or a 31 to 90

day supply of covered drugs and supplies through the Retail Pharmacy Program or up to a 30-day supply through the Specialty

Drug Pharmacy Program.

Notes:

- Certain drugs such as narcotics may have additional limits or requirements as established by the U.S. FDA or by national

scientific or medical practice guidelines (such as Centers for Disease Control, American Medical Association, etc.) on the

quantities that a pharmacy may dispense. In addition, pharmacy dispensing practices are regulated by the state where they are

located and may also be determined by individual pharmacies. Due to safety requirements, some medications are dispensed as

originally packaged by the manufacturer and we cannot make adjustments to the packaged quantity or otherwise open or split

packages to create 30, and 90-day supplies of those medications. In most cases, refills cannot be obtained until 75% of the

prescription has been used. Controlled substances cannot be refilled until 80% of the prescription has been used.

Controlled substances are medications that can cause physical and mental dependence, and have restrictions on how they can be

filled and refilled. They are regulated and classified by the DEA (Drug Enforcement Administration) based on how likely they

are to cause dependence. Call us or visit our website if you have any questions about dispensing limits. Please note that in the

event of a national or other emergency, or if you are a reservist or National Guard member who is called to active military duty,

you should contact us regarding your prescription drug needs. See the contact information on page 92.

91 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

- Benefits for certain self-injectable (self-administered) drugs are provided only when they are dispensed by a pharmacy under the

pharmacy benefit. Medical benefits will be provided for a once-per-lifetime dose per therapeutic category of drugs dispensed by

your provider or any non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B

coverage. See page 93 for specialty drug fills from a Preferred pharmacy.

- Benefits for certain auto-immune infusion medications (Remicade, Renflexis and Inflectra) are provided only when they are

obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). See

Drugs From

Other Sources

in this Section, page 100, for more information.

•Important contact information

- Retail Pharmacy Program: 800-624-5060, TTY: 800-624-5077

- Specialty Drug Pharmacy Program: 888-346-3731, TTY: 877-853-9549; or www.fepblue.org.

Patient Safety and Quality Monitoring (PSQM)

We have a special program to promote patient safety and monitor healthcare quality. Our Patient Safety and Quality Monitoring

(PSQM) program features a set of closely aligned programs that are designed to promote the safe and appropriate use of medications.

Examples of these programs include:

•Prior approval – As described below, this program requires that approval be obtained for certain prescription drugs and supplies

before we provide benefits for them.

•Safety checks – Before your prescription is filled, we perform quality and safety checks for usage precautions, drug interactions,

drug duplication, excessive use, and frequency of refills.

•Quantity allowances – Specific allowances for several medications are based on U.S. FDA-approved recommendations, national

scientific and generally accepted standards of medical practice guidelines (such as Centers for Disease Control, American Medical

Association, etc.), and manufacturer guidelines.

For more information about our PSQM program, including listings of drugs subject to prior approval or quantity allowances, visit our

website at www.fepblue.org or call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077.

Prior Approval

As part of our Patient Safety and Quality Monitoring (PSQM) program (see above), you must make sure your physician obtains

prior approval for certain prescription drugs and supplies in order to use your prescription drug coverage. In providing prior

approval, we may limit benefits to quantities prescribed in accordance with generally accepted standards of medical, dental, or

psychiatric practice in the United States. Our prior approval process may include step therapy, which requires you to use a generic

and/or preferred medication(s) before a non-preferred medication is covered. Prior approval must be renewed periodically. To

obtain a list of these drugs and supplies and to obtain prior approval request forms, call the Retail Pharmacy Program at

800-624-5060, TTY: 800-624-5077. You can also obtain the list and forms through our website at www.fepblue.org. Please read

Section 3 for more information about prior approval.

Notes:

•Updates to the list of drugs and supplies requiring prior approval are made periodically during the year. New drugs and supplies

may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval criteria are

not considered benefit changes.

•If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the drug or

supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for

instructions on how to file prescription drug claims.

•It is your responsibility to know the prior approval authorization expiration date for your medication. We encourage you to work

with your physician to obtain prior approval renewal in advance of the expiration date.

92 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

Benefits Description You Pay

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Covered Medications and Supplies FEP Blue Focus

Preferred retail pharmacies

Preferred Generic Drugs obtained at Preferred retail and overseas retail

pharmacies:

Tier 1

Notes:

• See Section 5(i), page 108, for information on how to file claims for

overseas services.

• For prescription drugs billed for by a skilled nursing facility, nursing home,

or extended care facility, we provide benefits as shown on this page for

drugs obtained from a Preferred retail pharmacy, as long as the pharmacy

supplying the prescription drugs to the facility is a Preferred pharmacy.

Preferred retail and overseas retail pharmacy:

• $5 copayment for each purchase of up to a 30-

day supply (no deductible)

• $15 copayment for each purchase of a 31 to 90-

day supply (no deductible)

Non-preferred pharmacy: You pay all charges

Preferred Brand-Name Drugs obtained at Preferred retail and overseas

retail pharmacies:

Tier 2

Notes:

• See Section 5(i), page 108, for information on how to file claims for

overseas services.

• For prescription drugs billed for by a skilled nursing facility, nursing home,

or extended care facility, we provide benefits as shown on this page for

drugs obtained from a Preferred retail pharmacy, as long as the pharmacy

supplying the prescription drugs to the facility is a Preferred pharmacy.

Preferred retail and overseas retail pharmacy:

• 40% of the Plan allowance (up to a $350

maximum) for each purchase of up to a 30-day

supply (no deductible)

• 40% of the Plan allowance (up to a $1,050

maximum) for each purchase of up to a 90-day

supply (no deductible)

Non-preferred pharmacy: You pay all charges

Preferred specialty drugs (generic and brand-name) obtained at

Preferred retail and overseas retail pharmacies:

Tier 2

• Benefits for specialty drugs purchased at a Preferred retail pharmacy are

limited to one purchase of up to a 30-day supply for each prescription

dispensed.

Notes:

• All refills must be obtained through the Specialty Drug Pharmacy Program.

See page 98 for more information.

• See the Specialty Drug Pharmacy Program for applicable cost-shares and

limits on page 98.

• Due to safety requirement, some medications are dispensed as originally

packaged by the manufacturer and we cannot make adjustment to the

packaged quantity or otherwise open or split packages to create a 30-day

supply of these medications.

• For prescription drugs billed for by a skilled nursing facility, nursing home,

or extended care facility, we provide benefits as shown on this page for

drugs obtained from a Preferred retail pharmacy, as long as the pharmacy

supplying the prescription drugs to the facility is a Preferred pharmacy.

• See Section 5(i), page 108, for information on how to file claims for

overseas services.

Preferred retail and overseas retail pharmacy:

• 40% of the Plan allowance (up to a $350

maximum) for each purchase of up to a 30-day

supply (no deductible)

• If a 31 to 90-day supply of a specialty drug has

to be dispensed due to manufacturer packaging,

you pay 40% of the Plan allowance (up to a

$1,050 maximum) for each purchase (no

deductible)

Non-preferred pharmacy: You pay all charges

Covered Medications and Supplies - continued on next page

93 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

Benefits Description You Pay

Covered Medications and Supplies (cont.) FEP Blue Focus

Tier 1 and 2 drugs purchased from a Preferred pharmacy include, but

are not limited to the following:

• Drugs, vitamins and minerals, and nutritional supplements included in our

closed formulary that by Federal law of the United States require a

prescription for their purchase

Note: See page 96 for our coverage of medications to promote better health

as recommended under the Affordable Care Act.

• Medical foods, as defined by the U.S. Food and Drug Administration, that

are consumed or administered enterally and are intended for the specific

dietary management of a disease or condition for which there are

distinctive nutritional requirements.

The Plan covers medical food formulas and enteral nutrition products that

are ordered by a healthcare provider, and are medically necessary to

prevent clinical deterioration in members at nutritional risk. (See Coverage

below)

- Must meet the definition of medical food (see definition on page 131)

- Must be receiving active, regular, and ongoing medical supervision and

must be unable to manage the condition by modification of diet alone

Coverage is provided as follows:

- Inborn errors of amino acid metabolism up to age 22

- Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE

mediation, malabsorption disorder, seizure disorder, failure to thrive, or

prematurity, when administered orally and is the sole source (100%) of

nutrition. This once per lifetime benefit is limited to one year following

the date of the initial prescription or physician order for the medical food

(e.g., Neocate, in a formula form or powders mixed to become formulas)

- Medical foods and nutritional supplements when administered by

catheter or nasogastric tubes

Notes:

- A prescription and prior approval are required for medical foods

provided under the pharmacy benefit. Renewals of the prior

authorization are required every benefit year for inborn errors of

metabolism and tube feeding.

- See Section 5(a), page 54, for our coverage of medical foods and

nutritional supplements when administered by catheter or nasogastric

tube under the medical benefit.

• Insulin, diabetic test strips, lancets and tubeless insulin delivery systems

Note: See page 53 for our coverage of insulin pumps with tubes.

• Needles and disposable syringes for the administration of covered

medications

• Clotting factors and anti-inhibitor complexes for the treatment of

hemophilia

See pages 93 and 97

Covered Medications and Supplies - continued on next page

94 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

Benefits Description You Pay

Covered Medications and Supplies (cont.) FEP Blue Focus

• Drugs to aid smoking and tobacco cessation that require a prescription by

federal law

Notes:

- We provide benefits for over-the-counter (OTC) smoking and tobacco

cessation medications only as described on page 98.

- You may be eligible to receive smoking and tobacco cessation

medications at no charge. See page 98 for more information.

• Drugs for the diagnosis of infertility, except as described on page 99

• Drugs to treat gender dysphoria (gonadotropin-releasing hormone (GnRH)

antagonists and testosterones

• Contraceptive drugs and devices, limited to:

- Diaphragms and contraceptive rings

- Injectable contraceptives

- Intrauterine devices (IUDs)

- Implantable contraceptives

- Oral and transdermal contraceptives

Note: We waive your cost-share for generic contraceptives and for brand-

name contraceptives that have no generic equivalent or generic alternative,

when you purchase them at a Preferred retail pharmacy.

See pages 93 and 98

Over-the-counter (OTC) contraceptive drugs and devices, for women only,

limited to:

• Emergency contraceptive pills

• Female condoms

• Spermicides

• Sponges

Note: We provide benefits in full for OTC contraceptive drugs and devices for

women only when the contraceptives meet U.S FDA standards for OTC

products. To receive benefits, you must use a Preferred retail pharmacy and

present the pharmacist with a written prescription from your physician.

Preferred retail and overseas retail pharmacy:

Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Note: See Section 5(i), page 108, for information

on how to file claims for overseas services.

Immunizations when provided by a Preferred retail pharmacy that participates

in our vaccine network (see below) and administered in compliance with

applicable state law and pharmacy certification requirements. See pages 42

and 44 for specific coverage.

Note: Our vaccine network is a network of Preferred retail pharmacies that

have agreements with us to administer one or more routine immunizations.

Check with your pharmacy or call our Retail Pharmacy Program at

800-624-5060, TTY: 800-624-5077, to find out which vaccines your

pharmacy can provide.

Preferred retail and overseas retail pharmacy:

Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Notes:

• You pay nothing for Influenza (flu) vaccines

obtained at Non-preferred retail pharmacies.

• See Section 5(i), page 108, for information on

how to file claims for overseas services.

Covered Medications and Supplies - continued on next page

95 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

Benefits Description You Pay

Covered Medications and Supplies (cont.) FEP Blue Focus

Diabetic Meter Program

Members with diabetes may obtain one glucose meter kit every 365 days at

no cost through our Diabetic Meter Program. To use this program, you must

call the phone number listed below and request one of the eligible types of

meters. The types of glucose meter kits available through our program are

subject to change.

To order your free glucose meter kit, call us toll-free at 855-582-2024,

Monday through Friday, from 9 a.m. to 7 p.m., Eastern Time, or visit our

website at www.fepblue.org. The selected meter kit will be sent to you within

7 to 10 days of your request.

Note: Contact your physician to obtain a new prescription for the test strips

and lancets to use with the new meter. Benefits will be provided for the test

strips at Tier 2 (preferred brand-name) benefit payment levels if you purchase

brand-name strips at a Preferred retail pharmacy. See page 97 for more

information.

Nothing for a glucose meter kit ordered through

our Diabetic Meter Program

When obtained from any other source: You pay all

charges

Medications to promote better health as recommended under the Patient

Protection and Affordable Care Act (the “Affordable Care Act”), limited to:

• Iron supplements for children from age 6 months through 12 months

• Oral fluoride supplements for children from age 6 months through 5 years

• Folic acid supplements, 0.4 mg to 0.8 mg, for women capable of pregnancy

• Low-dose aspirin (81 mg per day) for pregnant members at risk for

preeclampsia

• Aspirin for men age 45 through 79 and women age 50 through 79

• Generic cholesterol-lowering statin drugs

Notes:

• Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.

• Benefits for the medications listed above are subject to the dispensing

limitations described on pages 91-92 and are limited to recommended

prescribed limits.

• To receive benefits, you must use a Preferred retail pharmacy and present a

written prescription from your physician to the pharmacist.

• A complete list of USPSTF-recommended preventive care services is

available online at: www.healthcare.gov/preventive-care-benefits. See

pages 41-45 and 75 in Section 5(a) and 5(c) for information about other

covered preventive care services.

• See page 98 for our coverage of smoking and tobacco cessation

medications.

Preferred retail and overseas retail pharmacy:

Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Note: See Section 5(i), page 108, for information

on how to file claims for overseas services.

Generic medications to reduce breast cancer risk for women, age 35 or over,

who have not been diagnosed with any form of breast cancer

Note: Your physician must send a completed Coverage Request Form to CVS

Caremark before you fill the prescription. Call CVS Caremark at

800-624-5060, TTY: 800-624-5077, to request this form. You can also obtain

the Coverage Request Form through our website at www.fepblue.org.

Preferred retail and overseas retail pharmacy:

Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Covered Medications and Supplies - continued on next page

96 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

Benefits Description You Pay

Covered Medications and Supplies (cont.) FEP Blue Focus

We cover the first prescription filled for certain bowel preparation

medications for colorectal cancer screenings with no member cost-share. We

also cover certain antiretroviral therapy medications for HIV for those at

risk but who do not have HIV. You can view the list of covered medications

on our website at www.fepblue.org or call 800-624-5060, TTY:

800-624-5077, for assistance.

Preferred retail and overseas retail pharmacy:

Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Opioid Reversal Agents: Tier 1 medications limited to Narcan nasal spray and

naloxone generic injectable

Preferred retail and overseas retail pharmacy:

Nothing for the purchase of one 90-day supply per

calendar year (no deductible)

Note: Once you have purchased amounts of these

medications in a calendar year that are equivalent

to a 90-day supply combined, all Tier 1 fills

thereafter are subject to the corresponding cost-

share.

Non-preferred retail pharmacy: You pay all charges

Here is how to obtain your prescription drugs and supplies:

Preferred Retail Pharmacies

• Make sure you have your ID card when you are ready to purchase your

prescription.

• Go to any Preferred retail pharmacy, or

• Visit the website of your Preferred retail pharmacy to request your

prescriptions online and delivery, if available.

• For a listing of Preferred retail pharmacies, call the Retail Pharmacy

Program at 800-624-5060, TTY: 800-624-5077, or visit our website, www.

fepblue.org.

Notes:

• Benefits for Tier 2 specialty drugs purchased at a Preferred retail pharmacy

are limited to one purchase of up to a 30-day supply for each prescription

dispensed. All refills must be obtained through the Specialty Drug

Pharmacy Program, see page 98 for more information.

• Retail pharmacies that are Preferred for prescription drugs are not

necessarily Preferred for durable medical equipment (DME) and medical

supplies. To receive Preferred benefits for DME and covered medical

supplies, you must use a Preferred DME or medical supply provider. See

Section 5(a) for the benefit levels that apply to DME and medical supplies.

• For prescription drugs billed for by a skilled nursing facility, nursing home,

or extended care facility, we provide benefits as shown on this page for

drugs obtained from a Preferred retail pharmacy, as long as the pharmacy

supplying the prescription drugs to the facility is a Preferred pharmacy.

• For a list of the Preferred Network Long Term Care pharmacies, call

800-624-5060, TTY: 800-624-5077.

• For coordination of benefits purposes, if you need a statement of Preferred

retail pharmacy benefits in order to file claims with your other coverage

when this Plan is the primary payor, call the Retail Pharmacy Program at

800-624-5060, TTY: 800-624-5077, or visit our website at www.fepblue.

org.

Preferred retail and overseas retail pharmacy:

Tier 1

• $5 copayment for each purchase of up to a 30-

day supply (no deductible)

• $15 copayment for each purchase of a 31 to 90-

day supply (no deductible)

Tier 2

• 40% of the Plan allowance (up to a $350

maximum) for each purchase of up to a 30-day

supply (no deductible)

• 40% of the Plan allowance (up to a $1,050

maximum) for each purchase of a 31 to 90-day

supply (no deductible)

Non-preferred pharmacy: You pay all charges

Covered Medications and Supplies - continued on next page

97 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

Benefits Description You Pay

Covered Medications and Supplies (cont.) FEP Blue Focus

Smoking and Tobacco Cessation Medications

If you are a covered member, you may be eligible to obtain specific

prescription generic and brand-name smoking and tobacco cessation

medications at no charge. Additionally, you may be eligible to obtain over-

the-counter (OTC) smoking and tobacco cessation medications, prescribed by

your physician, at no charge. These benefits are only available when you use a

Preferred retail pharmacy.

Note: There may be age-restrictions based on U.S. FDA guidelines for these

medications.

The following medications are covered through this program:

• Generic medications available by prescription:

- Bupropion ER 150 mg tablet

- Bupropion SR 150 mg tablet

• Brand-name medications available by prescription:

- Chantix 0.5 mg tablet

- Chantix 1 mg continuing monthly pack

- Chantix 1 mg tablet

- Chantix starting monthly pack

- Nicotrol cartridge inhaler

- Nicotrol NS Spray 10 mg/ml

• Over-the-counter (OTC) medications

Notes:

• To receive benefits for over-the-counter (OTC) smoking and tobacco

cessation medications, you must have a physician’s prescription for each

OTC medication that must be filled by a pharmacist at a Preferred retail

pharmacy.

• Regular prescription drug benefits will apply to purchases of smoking and

tobacco cessation medications not meeting these criteria. Benefits are not

available for over-the-counter (OTC) smoking and tobacco cessation

medications except as described above.

• See page 55 for our coverage of smoking and tobacco cessation treatment,

counseling, and classes.

Preferred retail pharmacy: Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Specialty Drug Pharmacy Program

We cover specialty drugs that are listed on the FEP Blue Focus Specialty

Drug List. This list is subject to change. For the most up-to-date list, call the

phone number below or visit our website, www.fepblue.org. (See page 134 for

the definition of “specialty drugs.”)

Each time you order a new specialty drug or refill, a Specialty Drug pharmacy

representative will work with you to arrange a delivery time and location that

are most convenient for you, as well as ask you about any side effects you

may be experiencing. See page 114 for more details about the Program.

Specialty Drug Pharmacy Program

Tier 2:

• 40% of the Plan allowance (up to a $350

maximum) for each purchase of up to a 30-day

supply (no deductible)

• If a 31 to 90-day supply of a specialty drug has

to be dispensed due to manufacturer packaging,

you pay 40% of the Plan allowance (up to a

$1,050 maximum) for each purchase (no

deductible).

Covered Medications and Supplies - continued on next page

98 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

Benefits Description You Pay

Covered Medications and Supplies (cont.) FEP Blue Focus

Note: Due to safety requirements, some medications are dispensed as

originally packaged by the manufacturer and we cannot make adjustments to

the packaged quantity or otherwise open or split packages to create a 30-day

supply of these medications.

with your specialty drug orders, please call 888-346-3731, TTY:

877-853-9549.

Continued from previous page:

Non-preferred specialty drug pharmacy: You pay

all charges

Not covered:

•

Drugs and supplies purchased from a Non-preferred pharmacy

•

Medical supplies such as dressings and antiseptics

•

Drugs and supplies for cosmetic purposes

•

Drugs and supplies for weight loss

•

Drugs for orthodontic care, dental implants, and periodontal disease

•

Drugs used in conjunction with assisted reproductive technology (ART)

and assisted insemination procedures

•

Insulin and diabetic supplies except when obtained from a Preferred retail

pharmacy or except when Medicare Part B is primary. See pages 53 and 94.

•

Medications and orally taken nutritional supplements that do not require a

prescription under Federal law even if your doctor prescribes them or if a

prescription is required under your state law

Note: See page 96 for our coverage of medications recommended under the

Affordable Care Act and page 98 for smoking and tobacco cessation

medications.

•

Medical foods administered orally are not covered if not obtained at a

Preferred retail pharmacy

Note: See Section 5(a), page 54, for our coverage of medical foods when

administered by catheter or nasogastric tube.

•

Products and foods other than liquid formulas or powders mixed to become

formulas; foods and formulas readily available in a retail environment and

marketed for persons without medical conditions; low-protein modified

foods (e.g., pastas, breads, rice, sauces and baking mixes); nutritional

supplements, energy products; and similar items

Note: See Section 5(a), page 54, for our coverage of medical foods and

nutritional supplements when administered by catheter or nasogastric tube.

•

Infant formula other than described on pages 54 and 94

•

Drugs not listed on the formulary or preferred drug list

•

Brand name opioids

•

Remicade, Renflexis, and Inflectra are not covered for prescriptions

obtained from a Preferred retail pharmacy, or through the Specialty Drug

Pharmacy Program

•

Drugs for which prior approval has been denied or not obtained

•

Drugs and supplies related to sexual dysfunction or sexual inadequacy

All charges

Covered Medications and Supplies - continued on next page

99 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

FEP Blue Focus

Benefits Description You Pay

Covered Medications and Supplies (cont.) FEP Blue Focus

•

Drugs and covered-drug-related supplies for the treatment of gender

dysphoria if not obtained from a Preferred retail pharmacy or the Specialty

Drug Pharmacy Program as described on pages 93 and 98

•

Drugs purchased through the mail or internet from pharmacies inside or

outside the United States by members located in the United States

•

Over-the-counter (OTC) contraceptive drugs and devices, except as

described on page 95

•

Drugs used to terminate pregnancy

•

Sublingual allergy desensitization drugs, except as described on page 48

All charges

Drugs From Other Sources FEP Blue Focus

Covered prescription drugs and supplies not obtained at a retail pharmacy or

through the Specialty Drug Pharmacy Program to include, but not limited to:

• Physician’s office – for more information refer to Section 5(a)

• Facility (inpatient or outpatient) – for more information refer to

Section 5(c)

• Hospice agency – for more information refer to Section 5(c)

• Drugs obtained at a physician’s office, inpatient or outpatient facility or

hospice agency while overseas, see Section 5(i)

• Drugs and supplies covered only under the medical benefit, see auto-

immune infusions below

• Prescription drugs obtained from a Preferred retail pharmacy, that are billed

by a skilled nursing facility, nursing home, or extended care facility, see

page 97

Preferred professional providers and facilities:

30% of the Plan allowance (deductible applies)

Non-preferred professional providers

(Participating/Non-participating) and Non-

preferred facilities (Member/Non-member): You

pay all charges

Auto-immune infusion medications: Remicade, Renflexis and Inflectra

Note: Benefits for certain auto-immune infusion medications (limited to

Remicade, Renflexis and Inflectra) are covered only when they are obtained

by a non-pharmacy provider, such as a physician or facility (hospital or

ambulatory surgical center).

Preferred professional providers and facilities:

30% of the Plan allowance (deductible applies)

Non-preferred professional providers

(Participating/Non-participating) and Non-

preferred facilities (Member/Non-member): You

pay all charges

100 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(f)

Section 5(g). Dental Benefits

FEP Blue Focus

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure

and are payable only when we determine they are medically necessary.

•If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your

FEHB Plan will be the primary payor for any covered services and your FEDVIP Plan will be secondary to

your FEHB Plan. See Section 9,

Coordinating Benefits with Medicare and Other Coverage

, for additional

information.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how cost-sharing

works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age

65 or over.

•The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family

enrollment). We state whether or not the calendar year deductible applies for each benefit listed in this

section.

•You must use Preferred providers in order to receive accidental dental injury benefits for treatment

after 72 hours of the accident. Covered services provided more than 72 hours after an accident are subject to

the deductible and coinsurance.

Benefits Description You Pay

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Accidental Injury Benefit FEP Blue Focus

We provide benefits for services, supplies, or appliances for dental care

necessary to promptly repair injury to sound natural teeth required as a result

of, and directly related to, an accidental injury. To determine benefit coverage,

we may require documentation of the condition of your teeth before the

accidental injury, documentation of the injury from your provider(s), and a

treatment plan for your dental care. We may request updated treatment plans

as your treatment progresses.

Notes:

• An accidental injury is an injury caused by an external force or element

such as a blow or fall and that requires immediate attention. Injuries to the

teeth while eating are not considered accidental injuries.

• A sound natural tooth is a tooth that is whole or properly restored

(restoration with amalgams or resin-based composite fillings only); is

without impairment, periodontal, or other conditions; and is not in need of

the treatment provided for any reason other than an accidental injury. For

purposes of this Plan, a tooth previously restored with a crown, inlay, onlay,

or porcelain restoration, or treated by endodontics, is not considered a

sound natural tooth.

• We provide benefits for accidental dental injury care in cases of

medical emergency when performed by Preferred or Non-preferred

providers. See Section 5(d) for the criteria we use to determine if

emergency care is required. You are responsible for the applicable cost-

share as shown here. If you use a Non-preferred provider, you may also be

responsible for any difference between our allowance and the billed

amount.

• All follow-up care must be performed and billed for by Preferred providers

to be eligible for benefits.

Treatment of an accidental dental injury within

72 hours:

Preferred: Nothing (no deductible)

Non-preferred professional providers (Participating

and Non-participating):

• Participating: Nothing (no deductible)

• Non-participating: Any difference between our

allowance and the billed amount (no deductible)

Treatment after the initial 72 hours:

Preferred: 30% of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating):

You pay all charges

101 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(g)

FEP Blue Focus

Benefits Description You Pay

Inpatient and Outpatient Facility Care FEP Blue Focus

We cover inpatient and outpatient hospital care, as well as anesthesia

administered at the facility,

• To treat children up to age 22 with severe dental caries, or

• When a non-dental physical impairment exists that makes hospitalization

necessary to safeguard the health of the patient (even if the dental

procedure itself is not covered).

See Section 5(c) for inpatient and outpatient

hospital benefits.

Not covered: Routine dental care All charges

102 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(g)

Section 5(h). Wellness and Other Special Features

FEP Blue Focus

Special Feature Description

Stay connected to your health and get the answers you need when you need them by using Health

Tools 24 hours a day, 365 days a year. Go to www.fepblue.org or call 888-258-3432 toll-free to

check out these valuable easy-to-use services:

• Talk directly with a Registered Nurse any time of the day or night via phone, secure email, or

live chat. Ask questions and get medical advice. Please keep in mind that benefits for any

healthcare services you may seek after using Health Tools are subject to the terms of your

coverage under this Plan.

• Personal Health Record – Access your secure online personal health record for information

such as the medications you’re taking, recent test results, and medical appointments. Update,

store, and track health-related information at any time.

• Blue Health Assessment – An online health and lifestyle questionnaire (see below).

• Online Health Coach (OHC) – Manage your health proactively by setting and managing

health goals, create a plan of care, track your progress, and pursue healthy activities. The OHC

offers members a combination of guidance, support, and resources.

• Health Topics and WebMD Videos offer an extensive variety of educational tools using

videos, recorded messages, and colorful online materials that provide up-to-date information

about a wide range of health-related topics.

Health Tools

All Blue Cross and Blue Shield Plans provide TTY access for the hearing impaired to access

information and receive answers to their questions.

Services for the Deaf and

Hearing Impaired

Our website, www.fepblue.org, adheres to the most current Section 508 Web accessibility standards

to ensure that visitors with visual impairments can use the site with ease.

Web Accessibility for the

Visually Impaired

Please refer to Section 5(i) for benefit and claims information for care you receive outside the

United States, Puerto Rico, and the U.S. Virgin Islands.

Travel Benefit/Services

Overseas

Our Healthy Families suite of resources is for families with children and teens, ages 2 to 19.

Healthy Families provides activities and tools to help parents teach their children about weight

management, nutrition, physical activity, and personal well-being. For more information, go to

www.fepblue.org.

Healthy Families

The Blue Health Assessment (BHA) questionnaire is an easy and engaging online health

evaluation program which can be completed in 10-15 minutes. Your BHA answers are evaluated to

create a unique health action plan. Based on the results of your BHA, you can select personalized

goals, receive supportive advice, and easily track your progress through our Online Health Coach.

Visit our website, www.fepblue.org, for more information and to complete the BHA so you can

receive your individualized results and begin working toward achieving your goals. You may also

request a printed BHA by calling 888-258-3432 toll-free.

Blue Health Assessment

The Hypertension Management Program gives members with hypertension (otherwise known as

high blood pressure) access to a free blood pressure monitor (BPM) to encourage members to make

healthier choices to reduce the potential for complications from cardiac disease.

To qualify, you must be the contract holder or covered spouse (age 18 and over) and have at least

one medical claim processed during the past 12 months reporting a diagnosis of hypertension or

high blood pressure. If you qualify, you will receive a letter and a notice will be sent to your

MyBlue account (visit www.fepblue.org to set up your account) with instructions on how you may

receive a blood pressure monitor from us at no cost if your healthcare provider’s treatment plan

includes home blood pressure monitoring for your diagnosis. You may receive this benefit once

every two years. If you have questions, please call the customer service phone number listed on the

back of your ID card.

Hypertension

Management Program

103 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(h)

FEP Blue Focus

The BPM must be received through this program. Benefits are not available for BPMs for members

who do not meet the criteria or for those who obtain a BPM outside of this program. For more

information, call us at the phone number on the back of your ID card.

Visit MyBlue Customer eService at www.fepblue.org/myblue or use the fepblue mobile app to

check the status of your claims, change your address of record, request claim forms, request an ID

card, and track how you use your benefits. Additional features include:

• Online EOBs – You will automatically be enrolled in online EOBs. This will allow you to

view, download, and print your explanation of benefits (EOB) forms. Simply log on to

MyBlue via www.fepblue.org/myblue and click on “View My Claims”; from there you can

search claims and select the “EOB” link next to each claim to access your EOB. Though your

EOBs will be typically available online, there are some instances where you will receive a paper

EOB and a form to complete. You can also access EOBs via the fepblue mobile app. Simply

link to MyBlue, and click on Claims.

• Opt into Paper EOBs – If you wish to receive paper EOBs, you may Log on to MyBlue home

page, click on “Member Preferences” from the navigation bar and opt in by selecting “paper

EOBs.”

• Personalized Messages – Our EOBs provide a wide range of messages just for you and your

family, ranging from preventive care opportunities to enhancements to our online services.

• Financial Dashboard – Log in to MyBlue to access important information in real time,

including deductibles, out-of-pocket costs, remaining covered provider visits, medical claims,

and pharmacy claims. You also can review your year-to-date summary of completed claims, and

pharmacy spending throughout the year.

MyBlue

Customer

eService

Visit www.fepblue.org/provider to access our National Doctor & Hospital Finder and other

nationwide listings of Preferred providers.

National Doctor &

Hospital Finder

If you have a rare or chronic disease or have complex healthcare needs, the Service Benefit Plan

offers two types of Care Management Programs that provide assistance with the coordination of

your care, provide member education and clinical support.

• Case Management provides members who have acute or chronic complex healthcare needs with

the services and assistance of a licensed healthcare professional with a nationally recognized

case management certification. Case managers may be a registered nurse, licensed social

worker, or other licensed healthcare professional practicing within the scope of their license,

who may work with you and your providers to assess your healthcare needs, coordinate needed

care and available resources, evaluate the outcomes of your care, and support and monitor the

progress of the member’s treatment plan and healthcare needs. Some members may receive

guidance and clinical support for an acute healthcare need while others may benefit from a short

term case management enrollment. Enrollment in case management requires your consent.

Members in case management are asked to provide verbal consent prior to enrollment in case

management and must provide written consent for case management.

Note: Benefits for care provided by residential treatment centers require written consent and

participation in Case Management prior to admission; please see pages 76, 87 and 107 for

additional information.

• Disease Management supports members who have diabetes, asthma, chronic obstructive

pulmonary disease (COPD), coronary artery disease, or congestive heart failure by helping them

adopt effective self-care habits to improve the self-management of their condition. If you have

been diagnosed with any of these conditions, we may send you information about the programs

available to you in your area.

If you have any questions regarding these programs, including if you are eligible for enrollment and

assistance with enrollment, please contact us at the customer service phone number on the back of

your ID card.

Care Management

Programs

104 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(h)

FEP Blue Focus

Under the Blue Cross and Blue Shield Service Benefit Plan’s FEP Blue Focus, our Case

Management process may include a flexible benefits option. This option allows professional case

managers at Local Plans to assist members with certain complex and/or chronic health issues by

coordinating complicated treatment plans and other types of complex patient care plans. Through

the flexible benefits option, case managers will review the member’s healthcare needs and may at

our sole discretion, identify a less costly alternative treatment plan for the member. The member (or

their healthcare proxy) and provider(s) must cooperate in the process. Case Management Program

enrollment is required for eligibility. Prior to the starting date of the alternative treatment plan,

members who are eligible to receive services through the flexible benefits option are required to

sign and return a written consent for case management and the alternative plan. If you and your

provider agree with the plan, alternative benefits will begin immediately and you will be asked to

sign an alternative benefits agreement that includes the terms listed below, in addition to any

other terms specified in the agreement. We must receive the consent for case management and

the alternative benefits agreement signed by the member/healthcare proxy before you receive

any services included in the alternative benefits agreement.

• Alternative benefits will be made available for a limited period of time and are subject to our

ongoing review. You must cooperate with and participate in the review process. Your provider

(s) must submit the information necessary for our reviews. You and/or your healthcare proxy

must participate in care conferences and caregiver training as requested by your provider(s) or

by us.

• We may revoke the alternative benefits agreement immediately at any time, if we discover we

were misled by the information given to us by you, your provider, or anyone else involved in

your care, or that you are not meeting the terms of the agreement.

• If we approve alternative benefits, we do not guarantee that they will be extended beyond the

limited time period and/or scope of the alternative benefits agreement or that they will be

approved in the future.

• The decision to offer alternative benefits is solely ours, and unless otherwise specified in the

alternative benefits agreement, we may at our sole discretion, withdraw those benefits at any

time and resume regular contract benefits.

• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the

disputed claims process.

If you sign the alternative benefits agreement, we will provide the agreed-upon alternative

benefits for the stated time period, unless we are misled by the information given to us or

circumstances change. Benefits as stated in this brochure will apply to all services and dates of care

not included in the alternative benefits agreement. You or your provider may request an extension

of the time period initially approved for alternative benefits, no later than five business days prior to

the end of the alternative benefits agreement. We will review the request, including the services

proposed as an alternative and the cost of those services, but benefits as stated in this brochure will

apply if we do not approve your request.

Note: If we deny a request for precertification or prior approval of regular contract benefits, as

stated in this brochure, or if we deny regular contract benefits for services you have already

received, you may dispute our denial of regular contract benefits under the OPM disputed claims

process (see Section 8).

Flexible Benefits Option

Go to www.fepblue.org/telehealth or call 855-636-1579, TTY: 855-636-1578, toll free to access on-

demand, affordable, high-quality care for adults and children experiencing non-emergency medical

issues, including treatment of minor acute conditions (see page 131 for definition), dermatology

care, counseling for mental health and substance use disorder, and nutritional counseling.

Note: This benefit is available only through the contracted telehealth provider network.

Telehealth Services

105 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(h)

FEP Blue Focus

The Routine Annual Physical Incentive Program rewards members for receiving a routine annual

physical exam. This incentive enables you to receive, at no cost, an incentive reward from our

“shopping mall.” To qualify, you must be the contract holder or covered spouse (over age 18),

receive an annual routine physical exam from a Preferred provider, and have an active MyBlue

account (visit www.fepblue.org to set up your account). Qualifying members will receive

notification through their MyBlue account with instructions on how to redeem this incentive.

Additional details are available on our website, www.fepblue.org/fepbluefocus. FEP Blue Focus

members may also call 800-411-BLUE (2583) for inquiries related to this incentive program.

Note: In order to receive your incentive, you must have received your annual physical no later than

December 31, 2022, and you must request your incentive before December 31, 2023. Please allow

ample time to complete all activities by this date. If these activities are not completed by the dates

listed above, the incentive will be forfeited. Product availability and shipping limitations may

apply. International shipping is not available.

Routine Annual Physical

Incentive Program

Blue Cross and Blue Shield’s fepblue mobile application is available for download for both iOS and

Android mobile phones. The application provides members with 24/7 access to helpful features,

tools and information related to Blue Cross and Blue Shield Service Benefit Plan’s FEP Blue Focus

benefits. Members can log in with their MyBlue

username and password to access personal

healthcare information such as benefits, out-of-pocket costs, deductibles (if applicable) and

physician visit limits. They can also view claims and approval status, view/share Explanation of

Benefits (EOBs), view/share member ID cards, locate Preferred providers, and connect with our

telehealth services.

The fepblue Mobile

Application

106 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(h)

Section 5(i). Services, Drugs, and Supplies Provided Overseas

FEP Blue Focus

If you travel or live outside the United States, Puerto Rico, and the U.S. Virgin Islands, you are still entitled to the benefits described

in this brochure. Unless otherwise noted in this Section, the same definitions, limitations, and exclusions also apply. Costs associated

with repatriation from an international location back to the United States are not covered. See Section 10 for a definition of

repatriation. See page 108 for the claims information we need to process overseas claims. We may request that you provide complete

medical records from your provider to support your claim. If you plan to receive healthcare services in a country sanctioned by the

Office of Foreign Assets Control (OFAC) of the U.S. Department of the Treasury, your claim must include documentation of a

government exemption under OFAC authorizing care in that country.

Please note that the requirements to obtain precertification for inpatient care and prior approval for those services listed in

Section 3 do not apply when you receive care overseas, with the exception of admissions for gender reassignment surgery (see

page 19 for information) and admissions to residential treatment centers. Prior approval is required for all non-emergent air

ambulance transport services for overseas members (refer to page 80 for more information). Protections offered under the

NSA (see page 29) do not apply to overseas claims.

We have a network of participating hospitals overseas that will file your claims for inpatient facility care for

you – without an advance payment for the covered services you receive. We also have a network of

professional providers who have agreed to accept a negotiated amount as payment in full for their services.

The Overseas Assistance Center can help you locate a hospital or physician in our network near where you

are staying. You may also view a list of our network providers on our website, www.fepblue.org. You will

have to file a claim to us for reimbursement for professional services unless you or your provider contacts the

Overseas Assistance Center in advance to arrange direct billing and payment to the provider.

If you are overseas and need assistance locating providers (whether in or out of our network), contact the

Overseas Assistance Center (provided by GMMI), by calling 804-673-1678. Members in the United States,

Puerto Rico, or the U.S. Virgin Islands should call 800-699-4337 or email the Overseas Assistance Center at

[email protected]. GMMI also offers emergency evacuation services to the nearest facility equipped

to adequately treat your condition, translation services, and conversion of foreign medical bills to U.S.

currency. You may contact one of their multilingual operators

24 hours a day, 365 days a year.

Overseas

Assistance

Center

For professional care you receive overseas, we provide benefits at Preferred benefit levels using either our

Overseas Fee Schedule, a customary percentage of the billed charge, or a provider-negotiated discount as our

Plan allowance. The requirement to use Preferred providers in order to receive benefits does not apply

when you receive overseas care.

When the Plan allowance is based on the Overseas Fee Schedule, you pay any difference between our

payment and the amount billed, in addition to any applicable deductible, coinsurance and/or copayment

amounts. When the Plan allowance is a provider-negotiated discount, you are only responsible for any

applicable deductible, coinsurance and/or copayment. You must also pay any charges for noncovered

services.

For inpatient facility care you receive overseas, we provide benefits at the Preferred level without member

cost-share, for admissions to a DoD facility, or when the Overseas Assistance Center (provided by GMMI)

has arranged direct billing or acceptance of a guarantee of benefits with the facility. For all other inpatient

facility care, you are responsible for any applicable deductible and coinsurance.

For outpatient facility care you receive overseas, we provide benefits at the Preferred level after you pay the

applicable deductible, copayment and/or coinsurance.

For transport services you receive overseas, we provide benefits for transport services to the nearest

hospital equipped to adequately treat your condition when the transport services are medically necessary. We

provide benefits as described in Section 5(c) and Section 5(d). Benefits are not available for costs associated

with transportation to other than the closest hospital equipped to treat your condition. You are responsible for

any deductible and coinsurance and/or copayments. You must also pay any charges for noncovered services.

Hospital and

professional

provider

benefits

107 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Section 5(i)

FEP Blue Focus

For prescription drugs purchased at overseas pharmacies, we provide benefits at Preferred benefit levels,

using the billed charge as our Plan allowance. You pay the applicable copayment or coinsurance. The

calendar year deductible is not applicable when purchasing drugs at pharmacies located overseas. See page

93 in Section 5(f) for more information.

Pharmacy

benefits

Most overseas providers are under no obligation to file claims on behalf of our members. Follow the

procedures listed below to file claims for covered services and drugs you receive outside the United States,

Puerto Rico, and the U.S. Virgin Islands. You may need to pay for the services at the time you receive

them and then send a claim to us for reimbursement. We will provide translation and currency conversion

services for your overseas claims.

Overseas claims

payment

To file a claim for covered hospital and professional provider services received outside the United States,

Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Overseas Medical Claim Form, by mail,

fax, or internet, along with itemized bills from the provider. In completing the claim form, indicate whether

you want to be paid in U.S. dollars or in the currency reflected on the itemized bills, and if you want to

receive payment by check or bank wire. Use the following information to mail, fax, or submit your claim

electronically:

1. Mail: Federal Employee Program, Overseas Claims, P.O. Box 260070, Pembroke Pines, FL 33026.

2. Fax: 001-954-308-3957. Be sure to first dial the AT&T Direct Access Code of the country from which

you are faxing the claim.

3. Internet: Go to the MyBlue portal on www.fepblue.org. If you are already a registered MyBlue portal

user, click on the “Health Tools” menu and, in the “Get Care” section, select “Submit Overseas Claim”

and follow the instructions for submitting a medical claim. If you are not yet a registered user, go to

MyBlue, click on the “Sign Up” link, and register to use the online filing process.

If you have questions about your medical claims, call us at 888-999-9862, using the AT&T Direct Access

Code of the country from which you are calling, or email us through our website (www.fepblue.org) via the

MyBlue portal. You may also write to us at: Mailroom Administrator, FEP Overseas Claims, P.O. Box 14112,

Lexington, KY 40512-4112. You may obtain Overseas Medical Claim Forms from our website, by email at

[email protected] or from your Local Plan.

Filing overseas

claims

Drugs purchased overseas must be the equivalent to drugs that by Federal law of the United States require a

prescription. To file a claim for covered drugs and supplies you purchase from pharmacies outside the United

States, Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Retail Prescription Drug Overseas

Claim Form, along with itemized pharmacy receipts or bills. The timely filing deadline for overseas

pharmacy claims is limited to one year from the prescription fill date. Use the following information to mail,

fax, or submit your claim electronically:

1. Mail: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057,

Phoenix, AZ 85072-2057.

2. Fax: 001-480-614-7674. Be sure to first dial the AT&T Direct Access Code of the country from which

you are faxing the claim.

3. Internet: Go to the MyBlue portal on www.fepblue.org. If you are already a registered MyBlue portal

user, click on the “Health Tools” menu and, in the “Get Care” section, select “Submit Overseas Claim”

and follow the instructions for submitting a pharmacy claim. If you are not yet a registered user, go to

MyBlue, click on the “Sign Up” link, and register to use the online filing process.

Send any written inquiries concerning drugs you purchase overseas to: Blue Cross and Blue Shield Service

Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057. You may obtain FEP

Retail Prescription Drug Overseas Claim forms for your drug purchases by visiting our website, www.

fepblue.org, by writing to the address above, or by calling us at 888-999-9862, using the AT&T Direct

Access Code of the country from which you are calling.

While overseas, you may be able to order your prescription drugs through our Specialty Drug Pharmacy

Program as long as all of the following conditions are met:

• Your address includes a U.S. ZIP code (such as with APO and FPO addresses and in U.S. territories),

Filing a claim

for pharmacy

benefits

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FEP Blue Focus

• The prescribing physician is licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, and

has a National Provider Identifier (NPI), and

• Delivery of the prescription is permitted by law and is in accordance with the manufacturer’s guidelines.

See Section 5(f) for more information about Preferred retail pharmacies with online ordering and delivery

options, and the Specialty Drug Pharmacy Program.

Note: In most cases, temperature-sensitive drugs cannot be sent to APO/FPO addresses due to the special

handling they require.

Note: We are unable to ship drugs, through our Specialty Drug Pharmacy Program, to overseas countries that

have laws restricting the importation of prescription drugs from any other country. This is the case even when

a valid APO or FPO address is available. If you are living in such a country, you may obtain your

prescription drugs from a local overseas pharmacy and submit a claim to us for reimbursement by faxing it to

001-480-614-7674 or filing it via our website at www.fepblue.org/myblue.

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Non-FEHB Benefits Available to Plan Members

These benefits are not part of the FEHB contract or premium, and you cannot file an FEHB dispute regarding these benefits. Fees paid

for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. In addition, these

services are not eligible for benefits under the FEHB Program. Please do not file a claim for these services. These programs and

materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information, contact us at the

phone number on the back of your ID card or visit our website at www.fepblue.org.

Blue365

– The Blue Cross and Blue Shield Service Benefit Plan presents Blue365, a program that offers exclusive health and

wellness deals that will assist in your efforts to be healthy and happy, every day of the year. Blue365 delivers top discounts from

national and local retailers such as hearing aids through TruHearing, healthy food delivery via Sun Basket, wearable devices from

Fitbit, and genetic composition testing by Molecular Fitness, just to name a few. Each week, Blue365 members receive great health

and wellness deals via email. With Blue365, there is no paperwork to fill out. Just visit www.fepblue.org/blue365. Select Get Started

and then log in to MyBlue with your username and password to learn more about the various Blue365 vendors and discounts. The

Blue Cross and Blue Shield Service Benefit Plan may receive payments from Blue365 vendors. The Plan does not recommend,

endorse, warrant, or guarantee any specific Blue365 vendor or item. Vendors and the program are subject to change at any time.

Health Club Memberships – Fitness Your Way by Tivity Health can help you meet your health and fitness goals, on your budget,

and on your own time. Fitness Your Way by Tivity Health offers access to more than 10,000 different fitness locations for a discounted

monthly rate. You’ll have access to well-being support, health articles, and online health coaching, as well as exercise tracking and

nutrition goals, social networking, rewards, and the Daily Challenge 24 hours a day, 7 days a week. For more information or to enroll,

visit www.fepblue.org/healthclub or call customer service at 888-242-2060, Monday through Friday, 8 a.m. – 8 p.m., in all U.S. time

zones.

Discount Drug Program – The Discount Drug Program is available to members at no additional premium cost. It enables you to

purchase, at discounted prices, certain prescription drugs that are not covered by the regular prescription drug benefit. Discounts vary

by drug product, but average about 24%. The program permits you to obtain discounts on several drugs related to dental care, weight

loss, hair removal and hair growth, and other miscellaneous health conditions. Please refer to www.fepblue.org/ddp for a full list of

discounted drugs, including those that may be added to this list as they are approved by the U.S. Food and Drug Administration (U.S.

FDA). To use the program, simply present a valid prescription and your ID card at a Preferred retail pharmacy. The pharmacist will

ask you for payment in full at the negotiated discount rate. For more information, visit www.fepblue.org/ddp or call 800-624-5060.

Vision Care Affinity Program – Service Benefit Plan members can receive routine eye exams, frames, lenses, and conventional

contact lenses at substantial savings when using Davis Vision network providers. Members can also save up to 25% off the provider’s

usual fee, or 5% off sales pricing, on laser vision correction procedures. There are over 48,000 points of access including optometrists,

ophthalmologists, and many retailers. For a complete description of the program or to find a provider near you, go to www.fepblue.

org/vcap. You may also call us at 888-897-9350 between 8:00 a.m. and 11:00 p.m. Eastern Time, Monday to Friday; 9:00 a.m. to 4:00

p.m. on Saturday; or noon to 4:00 p.m. on Sunday. Please be sure to verify that the provider participates in our Vision Care Affinity

Program and ask about the discounts available before your visit, as discounts may vary.

110 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Non-FEHB Benefits Available to Plan Members

Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover

The exclusions in this Section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure.

Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically necessary to

prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific

services, such as transplants, see Section 3,

You need prior Plan approval for certain services

We do not cover the following:

•Services, drugs, or supplies you receive while you are not enrolled in this Plan.

•Services, drugs, or supplies that are not medically necessary.

•Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice in the United

States.

•Services, drugs, or supplies billed by Preferred and Member facilities for inpatient care related to specific medical errors and

hospital-acquired conditions known as Never Events (see definition on page 131).

•Experimental or investigational procedures, treatments, drugs, or devices (see Section 5(b) regarding transplants).

•Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to

term, or when the pregnancy is the result of an act of rape or incest.

•Services, drugs, or supplies related to sexual dysfunction or sexual inadequacy (except for surgical placement of penile prostheses

to treat erectile dysfunction and gender reassignment surgeries specifically listed as covered).

•Travel expenses except as specifically provided for covered transplants performed in a Blue Distinction Center for Transplant (see

page 67).

•Services, drugs, or supplies you receive from a provider or facility barred or suspended from the FEHB Program.

•Services, drugs, or supplies you receive in a country sanctioned by the Office of Foreign Assets Control (OFAC) of the U.S.

Department of the Treasury, from a provider or facility not appropriately licensed to deliver care in that country.

•Services or supplies for which no charge would be made if the covered individual had no health insurance coverage.

•Services, drugs, or supplies you receive without charge while in active military service.

•Charges which the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not

covered by Medicare Parts A and/or B (see page 125), doctor’s charges exceeding the amount specified by the Department of

Health & Human Services when benefits are payable under Medicare (limiting charge, see page 126), or state premium taxes

however applied.

•Prescriptions, services or supplies ordered, performed, or furnished by you or your immediate relatives or household members, such

as spouse, parents, children, brothers, or sisters by blood, marriage, or adoption.

•Services or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs; oxygen; and

physical, speech, and occupational therapy provided by a qualified professional therapist on an outpatient basis are covered subject

to Plan limits.

•Services, drugs, or supplies you receive from noncovered providers.

•Services, drugs, or supplies you receive for cosmetic purposes.

•Services, drugs, or supplies for the treatment of obesity, weight reduction, or dietary control, except for office visits, diagnostic

tests, and procedures and services for the treatment of morbid obesity listed on pages 57-58.

•Services you receive from a provider that are outside the scope of the provider’s licensure or certification.

•Any dental or oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or

preparing the mouth for the fitting or continued use of dentures, except as specifically described in Section 5(g),

Dental Benefits

and Section 5(b) under

Oral and Maxillofacial Surgery

•Dental and orthodontic services, except for treatment of accidental injury as described on page 101, or oral surgery as described on

page 61.

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Section 6

•Orthodontic care for malposition of the bones of the jaw or for temporomandibular joint (TMJ) syndrome.

•Services of standby physicians.

•Self-care or self-help training.

•Custodial or long term care (see

Definitions

•Personal comfort items such as beauty and barber services, radio, television, or phone.

•Furniture (other than medically necessary durable medical equipment) such as commercial beds, mattresses, chairs.

•Routine services, such as periodic physical examinations; screening examinations; immunizations; and services or tests not related

to a specific diagnosis, illness, injury, set of symptoms, or maternity care, except for those preventive services specifically covered

under Preventive Care, Adult and Preventive Care, Child in Sections 5(a) and 5(c), the preventive screenings specifically listed on

pages 41-45 and page 75; and certain routine services associated with covered clinical trials (see pages 121-122).

•Recreational or educational therapy, and any related diagnostic testing, except as provided by a hospital during a covered inpatient

stay.

•Applied behavior analysis (ABA) and related services for any condition other than an autism spectrum disorder.

•Applied behavior analysis (ABA) services and related services performed as part of an educational program; or provided in or by a

school/educational setting; or provided as a replacement for services that are the responsibility of the educational system.

•Topical Hyperbaric Oxygen Therapy (THBO).

•Research costs (costs related to conducting a clinical trial such as research physician and nurse time, analysis of results, and clinical

tests performed only for research purposes).

•Professional charges for after-hours care, except when associated with services provided in a physician's office.

•Incontinence products such as incontinence garments (including adult or infant diapers, briefs, and underwear), incontinence pads/

liners, bed pads, or disposable washcloths.

•Alternative medicine services including, but not limited to, botanical medicine, aromatherapy, herbal/nutritional supplements (see

page 99), meditation techniques, relaxation techniques, movement therapies, and energy therapies.

•Services, drugs, or supplies related to medical marijuana.

•Hearing aids including bone-anchored hearing aids.

•Advanced care planning, except when provided as part of a covered hospice care treatment plan (see page 78).

•Membership or concierge service fees charged by a healthcare provider.

•Fees associated with copies, forwarding or mailing of records except as specifically described in Section 8.

•Services not specifically listed as covered.

•Services or supplies we are prohibited from covering under the Federal Law.

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Section 6

Section 7. Filing a Claim for Covered Services

This Section primarily deals with post-service claims (claims for services, drugs, or supplies you have already received).

See Section 3 for information on pre-service claims procedures (services, drugs, or supplies requiring precertification or prior

approval), including urgent care claims procedures.

To obtain claim forms or other claims filing advice, or answers to your questions about our benefits,

fepblue.org.

In most cases, physicians and facilities file claims for you. Just present your ID card when you receive

services. Your provider must file on the CMS-1500, Health Insurance Claim Form. Your facility will file

on the UB-04 form.

When you must file a claim – such as when another group health plan is primary – submit it on the

CMS-1500 or a claim form that includes the information shown below. Use a separate claim form for each

family member. For long or continuing inpatient stays, or other long-term care, you should submit claims

at least every 30 days. Bills and receipts should be itemized and show:

• Patient’s name, date of birth, address, phone number, and relationship to enrollee

• Patient’s Plan identification number

• Name and address of person or company providing the service or supply

• Dates that services or supplies were furnished

• Diagnosis

• Type of each service or supply

• Charge for each service or supply

Note: Canceled checks, cash register receipts, balance due statements, or bills you prepare yourself are not

acceptable substitutes for itemized bills.

In addition:

• If another health plan is your primary payor, you must send a copy of the explanation of benefits

(EOB) form you received from your primary payor (such as the Medicare Summary Notice (MSN))

with your claim.

• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.

• If your claim is for the rental or purchase of durable medical equipment, home nursing care, or

physical, occupational, speech, or cognitive rehabilitation therapy, you must provide a written

statement from the provider specifying the medical necessity for the service or supply and the length

of time needed.

• Claims for dental care to repair accidental injury to sound natural teeth should include documentation

of the condition of your teeth before the accidental injury, documentation of the injury from your

provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your

treatment progresses.

Claims for prescription drugs and supplies that are not received from the Retail Pharmacy Program must

include receipts that show the prescription number, name of drug or supply, prescribing provider’s name,

date, and charge. (See pages 97-99 for information on how to obtain benefits from the Retail Pharmacy

Program and the Specialty Drug Pharmacy Program.)

How to claim

benefits

We will notify you of our decision within 30 days after we receive your post-service claim. If matters

beyond our control require an extension of time, we may take up to an additional 15 days for review and

we will notify you before the expiration of the original 30-day period. Our notice will include the

circumstances underlying the request for the extension and the date when a decision is expected.

Post-service claims

procedures

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If we need an extension because we have not received necessary information (e.g., medical records) from

you, our notice will describe the specific information required and we will allow you up to 60 days from

the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims

process detailed in Section 8 of this brochure.

Preferred Retail Pharmacies – When you use Preferred retail pharmacies, show your ID card. To find a

Preferred retail pharmacy, visit www.fepblue.org/provider. If you use a Preferred retail pharmacy that

offers online ordering, have your ID card ready to complete your purchase. Preferred retail pharmacies file

your claims for you. We reimburse them for your covered drugs and supplies. You pay the applicable

coinsurance or copayment.

Note: Even if you use Preferred retail pharmacies, you will have to file a paper claim form to obtain

reimbursement if:

• You do not have a valid ID card;

• You do not use your valid ID card at the time of purchase; or

• You did not obtain prior approval when required (see page 22).

See the following paragraphs for claim filing instructions.

Non-Preferred Retail Pharmacies: There are no benefits for drugs or supplies purchased at Non-

preferred retail pharmacies. Note: For overseas pharmacy, see page 108.

Specialty Drug Pharmacy Program

If your physician prescribes a specialty drug that appears on our FEP Blue Focus Specialty Drug List, your

physician may order the initial prescription by calling our Specialty Drug Pharmacy Program at

888-346-3731, TTY: 877-853-9549, or you may send your prescription to: BCBS FEP Specialty Drug

Pharmacy Program, CVS Specialty, 9310 Southpark Center Loop, Orlando, FL 32819. You will be billed

later for the copayment. The Specialty Drug Pharmacy Program will work with you to arrange a delivery

time and location that is most convenient for you. To order refills, call the same phone number to arrange

your delivery. You may either charge your copayment to your credit card or have it billed to you later.

Note: For the most up-to-date listing of covered specialty drugs, call the Specialty Drug Pharmacy

Program at 888-346-3731, TTY: 877-853-9549, or visit our website, www.fepblue.org.

Prescription drug

claims

Keep a separate record of the medical expenses of each covered family member, because deductibles and

benefit maximums (such as those for outpatient physical therapy) apply separately to each person. Save

copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they

will serve as evidence of your claim. We will not provide duplicate or year-end statements.

Records

Send us your claim and appropriate documentation as soon as possible. You must submit the claim by

December 31 of the year after the year you received the service, unless timely filing was prevented by

administrative operations of Government or legal incapacity, provided you submitted the claim as soon as

reasonably possible. If we return a claim or part of a claim for additional information (e.g., diagnosis

codes, dates of service, etc.), you must resubmit it within 90 days, or before the timely filing period

expires, whichever is later.

Note: Timely filing for overseas pharmacy claims is limited to one year from the prescription fill date.

Note: Once we pay benefits, there is a five-year limitation on the re-issuance of uncashed checks.

Deadline for filing

your claim

Please refer to the claims filing information on page 108 of this brochure. Overseas claims

Please reply promptly when we ask for additional information. We may delay processing or deny benefits

for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await

all of the additional information needed to process your claim.

When we need

more information

114 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims

decisions to us. For urgent care claims, a healthcare professional with knowledge of your medical

condition will be permitted to act as your authorized representative without your express consent. For the

purposes of this Section, we are also referring to your authorized representative when we refer to you.

Authorized

representative

The Secretary of Health and Human Services has identified counties where at least 10 percent of the

population is literate only in certain non-English languages. The non-English languages meeting this

threshold in certain counties are Spanish, Chinese, Navajo, and Tagalog. If you live in one of these

counties, we will provide language assistance in the applicable non-English language. You can request a

copy of your explanation of benefits (EOB) statement, related correspondence, oral language services

(such as phone customer assistance), and help with filing claims and appeals (including external reviews)

in the applicable non-English language. The English versions of your EOBs and related correspondence

will include information in the non-English language about how to access language services in that non-

English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit

determination will include information sufficient to identify the claim involved (including the date of

service, the healthcare provider, and the claim amount, if applicable), and a statement describing the

availability, upon request, of the diagnosis code and its corresponding meaning, and the procedure or

treatment code and its corresponding meaning.

Notice

requirements

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Section 8. The Disputed Claims Process

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your

post-service claim (a claim where services, drugs, or supplies have already been provided). In Section 3,

If you disagree with our pre-

service claim decision

, we describe the process you need to follow if you have a claim for services, drugs, or supplies that must have

precertification (such as inpatient hospital admissions) or prior approval from the Plan.

You may appeal directly to the U.S. Office of Personnel Management (OPM) if we do not follow required claims processes. For more

information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional

requirements not listed in Sections 3, 7, and 8 of this brochure, please call your Plan’s customer service representative at the phone

number found on your identification card, plan brochure, or plan website (www.fepblue.org).

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan

documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your

request, please call us at the customer service phone number on the back of your ID card, or send your request to us at the address

shown on your explanation of benefits (EOB) form for the Local Plan that processed the claim (or, for Prescription drug benefits, our

Retail Pharmacy Program, or the Specialty Drug Pharmacy Program).

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the

claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational),

we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the

medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their

subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any

individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of

benefits.

Step Description

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at the address shown on your explanation of benefits (EOB) form for the Local Plan that

processed the claim (or, for Prescription drug benefits, our Retail Pharmacy Program or the Specialty Drug Pharmacy

Program); and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this

brochure; and

d) Include copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical

records, and explanation of benefits (EOB) forms.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon,

or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will

provide you with this information sufficiently in advance of the date that we are required to provide you with our

reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to

provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our

decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in

Step 3.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

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Section 8

c) Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide

within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We

will base our decision on the information we already have. We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or

• 120 days after you first wrote to us – if we did not answer that request in some way within 30 days; or

• 120 days after we asked for additional information – if we did not send you a decision within 30 days after we received

the additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance

Operations, FEHB 1, 1900 E Street NW, Washington, DC 20415-3610.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

• Copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical records, and

explanation of benefits (EOB) forms;

• Copies of all letters you sent to us about the claim;

• Copies of all letters we sent to you about the claim;

• Your daytime phone number and the best time to call; and

• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email

address, you may receive OPM’s decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative,

such as medical providers, must include a copy of your specific written consent with the review request. However, for

urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized

representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons

beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether

our decision is correct. OPM will determine if we correctly applied the terms of our contract when we denied your claim

or request for service. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit

against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services,

drugs, or supplies, or from the year in which you were denied precertification or prior approval. This is the only deadline

that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claims decision. This

information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your

lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when

OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

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Section 8

Note: If you have a serious or life-threatening condition (one that may cause permanent loss of bodily functions or death if not treated

as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at the customer service phone

number on the back of your ID card. We will expedite our review (if we have not yet responded to your claim); or we will inform

OPM so they can quickly review your claim on appeal. You may call OPM’s FEHB 1 at 202-606-0727 between 8 a.m. and 5 p.m.

Eastern Time.

Please remember that we do not make decisions about Plan eligibility issues. For example, we do not determine whether you or a

dependent is covered under this Plan. You must raise eligibility issues with your agency personnel/payroll office if you are an

employee, your retirement system if you are an annuitant, or the Office of Workers’ Compensation Programs if you are receiving

Workers’ Compensation benefits.

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Section 8

Section 9. Coordinating Benefits With Medicare and Other Coverage

You must tell us if you or a covered family member has coverage under any other group

health plan or has automobile insurance that pays healthcare expenses without regard to

fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary

payor and the other plan pays a reduced benefit as the secondary payor. We, like other

insurers, determine which coverage is primary according to the National Association of

Insurance Commissioners’ (NAIC) guidelines. For example:

• If you are covered under our Plan as a dependent, any group health insurance you have from

your employer will pay primary and we will pay secondary.

• If you are an annuitant under our Plan and also are actively employed, any group health

insurance you have from your employer will pay primary and we will pay secondary.

• When you are entitled to the payment of healthcare expenses under automobile insurance,

including no-fault insurance and other insurance that pays without regard to fault, your

automobile insurance is the primary payor and we are the secondary payor.

For more information on NAIC rules regarding the coordinating of benefits, visit our website at

www.fepblue.org/coordinationofbenefits.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays,

we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our

allowance. For example, we will generally only make up the difference between the primary

payor’s benefits payment and 100% of the Plan allowance, subject to our applicable deductible and

coinsurance or copayment amounts, except when Medicare is the primary payor (see page 124).

Thus, it is possible that the combined payments from both plans may not equal the entire amount

billed by the provider.

Note: When we pay secondary to primary coverage you have from a prepaid plan (HMO), we base

our benefits on your out-of-pocket liability under the prepaid plan (generally, the prepaid plan’s

copayments), subject to our deductible and coinsurance or copayment amounts.

In certain circumstances when we are secondary and there is no adverse effect on you (that is, you

do not pay any more), we may also take advantage of any provider discount arrangements your

primary plan may have and only make up the difference between the primary plan’s payment and

the amount the provider has agreed to accept as payment in full from the primary plan.

Note: Any visit limitations that apply to your care under this Plan are still in effect when we are the

secondary payor.

Remember: Even if you do not file a claim with your other plan, you must still tell us that you have

double coverage, and you must also send us documents about your other coverage if we ask for

them.

Please see Section 4,

Your Costs for Covered Services

, for more information about how we pay

claims.

When you have other

health coverage

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the

military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to

disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover

you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have

questions about these programs.

• TRICARE and

CHAMPVA

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Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or

former spouse, you can suspend your FEHB coverage to enroll in one of these programs,

eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For

information on suspending your FEHB enrollment, contact your retirement office. If you later want

to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless

you involuntarily lose coverage under TRICARE or CHAMPVA.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the

Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency

determines they must provide; or

• OWCP or a similar agency pays for through a third-party injury settlement or other similar

proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or a similar agency pays its maximum benefits for your treatment, we will cover your

care.

• Workers’

Compensation

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of

medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB

coverage to enroll in one of these state programs, eliminating your FEHB premium. For

information on suspending your FEHB enrollment, contact your retirement office. If you later want

to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless

you involuntarily lose coverage under the state program.

• Medicaid

We do not cover services and supplies when a local, state, or federal government agency directly or

indirectly pays for them.

When other Government

agencies are responsible

for your care

If another person or entity, through an act or omission, causes you to suffer an injury or illness, and

if we paid benefits for that injury or illness, you must agree to the provisions listed below. In

addition, if you are injured and no other person or entity is responsible but you receive (or are

entitled to) a recovery from another source, and if we paid benefits for that injury, you must agree

to the following provisions:

• All recoveries you or your representatives obtain (whether by lawsuit, settlement, insurance or

benefit program claims, or otherwise), no matter how described or designated, must be used to

reimburse us in full for benefits we paid. Our share of any recovery extends only to the amount

of benefits we have paid or will pay to you, your representatives, and/or healthcare providers on

your behalf. For purposes of this provision, “you” includes your covered dependents, and “your

representatives” include, if applicable, your heirs, administrators, legal representatives, parents

(if you are a minor), successors, or assignees. This is our right of recovery.

• We are entitled under our right of recovery to be reimbursed for our benefit payments even if

you are not “made whole” for all of your damages in the recoveries that you receive. Our right

of recovery is not subject to reduction for attorney’s fees and costs under the “common fund” or

any other doctrine.

• We will not reduce our share of any recovery unless, in the exercise of our discretion, we agree

in writing to a reduction (1) because you do not receive the full amount of damages that you

claimed or (2) because you had to pay attorneys’ fees.

• You must cooperate in doing what is reasonably necessary to assist us with our right of

recovery. You must not take any action that may prejudice our right of recovery.

• If you do not seek damages for your illness or injury, you must permit us to initiate recovery on

your behalf (including the right to bring suit in your name). This is called subrogation.

When others are

responsible for injuries

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If you do seek damages for your illness or injury, you must tell us promptly that you have made a

claim against another party for a condition that we have paid or may pay benefits for, you must seek

recovery of our benefit payments and liabilities, and you must tell us about any recoveries you

obtain, whether in or out of court. We may seek a first priority lien on the proceeds of your claim in

order to reimburse ourselves to the full amount of benefits we have paid or will pay.

We may request that you sign a reimbursement agreement and/or assign to us (1) your right to bring

an action or (2) your right to the proceeds of a claim for your illness or injury. We may delay

processing of your claims until you provide the signed reimbursement agreement and/or

assignment, and we may enforce our right of recovery by offsetting future benefits.

Note: We will pay the costs of any covered services you receive that are in excess of any recoveries

made.

Our rights of recovery and subrogation as described in this Section may be enforced, at the

Carrier’s option, by the Carrier, by any of the Local Plans that administered the benefits paid in

connection with the injury or illness at issue, or by any combination of these entities. Please be

aware that more than one Local Plan may have a right of recovery/subrogation for claims arising

from a single incident (e.g., a car accident resulting in claims paid by multiple Local Plans) and that

the resolution by one Local Plan of its lien will not eliminate another Local Plan’s right of recovery.

Among the other situations covered by this provision, the circumstances in which we may

subrogate or assert a right of recovery shall also include:

• When a third party injures you, for example, in an automobile accident or through medical

malpractice;

• When you are injured on premises owned by a third party; or

• When you are injured and benefits are available to you or your dependent, under any law or

under any type of insurance, including, but not limited to:

- No-fault insurance and other insurance that pays without regard to fault, including personal

injury protection benefits, regardless of any election made by you to treat those benefits as

secondary to this Plan

- Uninsured and underinsured motorist coverage

- Workers’ Compensation benefits

- Medical reimbursement coverage

Some FEHB plans already cover some dental and vision services. When you are covered by more

than one dental/vision plan, coverage provided under your FEHB plan remains as your primary

coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or

vision plan, you will be asked to provide information on your FEHB plan so that your plans can

coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

When you have Federal

Employees Dental and

Vision Insurance Plan

(FEDVIP)

If you are a participant in an approved clinical trial, this health Plan will provide benefits for

covered related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for medically necessary services such as doctor visits, lab tests, X-

rays and scans, and hospitalizations related to treating the patient’s condition, whether the

patient is in a clinical trial or is receiving standard therapy. We provide benefits for these types

of costs at the benefit levels described in Section 5 (

Benefits

) when the services are covered

under the Plan and we determine that they are medically necessary.

Clinical trials

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• Extra care costs – costs of covered services related to taking part in a clinical trial such as

additional tests that a patient may need as part of the trial, but not as part of the patient’s routine

care. This Plan covers extra care costs related to taking part in an approved clinical trial for a

covered stem cell transplant such as additional tests that a patient may need as part of the

clinical trial protocol, but not as part of the patient’s routine care. For more information about

approved clinical trials for covered stem cell transplants, see pages 64-65. Extra care costs

related to taking part in any other type of clinical trial are not covered. We encourage you

to contact us at the customer service phone number on the back of your ID card to discuss

specific services if you participate in a clinical trial.

• Research costs – costs related to conducting the clinical trial such as research physician and

nurse time, analysis of results, and clinical tests performed only for research purposes. These

costs are generally covered by the clinical trials. This Plan does not cover these costs.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is

conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening

disease or condition, and is either Federally funded; conducted under an investigational new drug

application reviewed by the Food and Drug Administration (U.S. FDA); or is a drug trial that is

exempt from the requirement of an investigational new drug application.

For more detailed information on “What is Medicare?” and “Should I enroll in Medicare?” please

contact Medicare at 1-800-Medicare 800-633-4227, TTY: 877-486-2048, or at www.medicare.gov.

When you have Medicare

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is

the way everyone used to get Medicare benefits and is the way most people get their Medicare Part

A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare.

The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for

members with Medicare Part B, when Medicare is primary. This is true whether or not they accept

Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules

in this brochure for us to cover your care. For example, you must continue to obtain prior approval

for some prescription drugs and organ/tissue transplants before we will pay benefits. However, you

do not have to precertify inpatient hospital stays when Medicare Part A is primary (see page 19 for

exceptions).

Claims process when you have the Original Medicare Plan – You will probably not need to file a

claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When the Original Medicare Plan is the primary payor, Medicare processes your claim first. In

most cases, your claim will be coordinated automatically and we will then provide secondary

benefits for the covered charges. To find out if you need to do something to file your claims, call us

at the customer service phone number on the back of your ID card or visit our website at www.

fepblue.org.

We waive some costs if the Original Medicare Plan is your primary payor – We will waive

some out-of-pocket costs as follows:

When Medicare Part A is primary –

• We will waive our calendar year deductible and coinsurance

• Once you have exhausted your Medicare Part A benefits, you must then pay the coinsurance

once the calendar year deductible has been satisfied for the inpatient admission.

Note: Precertification is required.

• The Original

Medicare Plan (Part

A or Part B)

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When Medicare Part B is primary –

• We will waive our calendar year deductible, coinsurance and copayments for inpatient and

outpatient services and supplies provided by physicians and other covered healthcare

professional and outpatient facility services.

Note: We do not waive benefit limitations, such as the 10-visit limit for home skilled nursing visits.

In addition, we do not waive any coinsurance or copayments for prescription drugs.

You can find more information about how our Plan coordinates benefits with Medicare in our

Medicare and You Guide for Federal Employees

available online at www.fepblue.org.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain

information about services denied or paid under Medicare if we ask. You must also tell us about

other coverage you or your covered family members may have, as this coverage may affect the

primary/secondary status of this Plan and Medicare.

• Tell us about your

Medicare coverage

If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing

that you can be billed directly for services ordinarily covered by Original Medicare. Should you

sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our

payment. We will still limit our payment to the amount we would have paid after Original

Medicare’s payment. You may be responsible for paying the difference between the billed amount

and the amount we paid.

• Private contract with

your physician

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a

Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in

some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at

800-MEDICARE (800-633-4227), TTY: 877-486-2048, or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s

Medicare Advantage plan and also remain enrolled in our FEHB Plan. If you enroll in a Medicare

Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in

a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

We provide benefits for care received from Preferred providers when your Medicare Advantage

plan is primary, even out of the Medicare Advantage plan’s network and/or service area. However,

we will not waive any of our copayments or coinsurance for services you receive from Preferred

providers who do not participate in the Medicare Advantage plan. Please remember that you must

receive care from Preferred providers in order to receive benefits. See page 18 for the exceptions to

this requirement.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or

former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan,

eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan

premium.) For information on suspending your FEHB enrollment, contact your retirement office. If

you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open

Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s

service area.

• Medicare Advantage

(Part C)

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we

are the secondary payor, we will review claims for your prescription drug costs that are not covered

by Medicare Part D and consider them for payment under the FEHB plan.

• Medicare

prescription drug

coverage (Part D)

This health plan does not coordinate its prescription drug benefits with Medicare Part B. • Medicare

prescription drug

coverage (Part B)

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Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates whether

Medicare or this Plan should be the primary payor for you according to your employment status and other factors determined by

Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these

requirements correctly. (Having coverage under more than two health plans may change the order of benefits determined on

this chart.)

Primary Payor Chart

A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the

individual with Medicare is...

Medicare This Plan

1) Have FEHB coverage on your own as an active employee

2) Have FEHB coverage on your own as an annuitant or through your spouse who is an

annuitant

3) Have FEHB through your spouse who is an active employee

4) Are a reemployed annuitant with the Federal government and your position is excluded from

the FEHB (your employing office will know if this is the case) and you are not covered under

FEHB through your spouse under #3 above

5) Are a reemployed annuitant with the Federal government and your position is not excluded

from the FEHB (your employing office will know if this is the case) and...

• You have FEHB coverage on your own or through your spouse who is also an active

employee

• You have FEHB coverage through your spouse who is an annuitant

6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired

under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and

you are not covered under FEHB through your spouse under #3 above

7) Are enrolled in Part B only, regardless of your employment status

for Part B

services

for other

services

8) Are a Federal employee receiving Workers' Compensation

9) Are a Federal employee receiving disability benefits for six months or more

B. When you or a covered family member...

1) Have Medicare solely based on end stage renal disease (ESRD) and...

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD

(30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled

to Medicare due to ESRD

2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...

• This Plan was the primary payor before eligibility due to ESRD (for 30 month

coordination period)

• Medicare was the primary payor before eligibility due to ESRD

3) Have Temporary Continuation of Coverage (TCC) and...

• Medicare based on age and disability

• Medicare based on ESRD (for the 30 month coordination period)

• Medicare based on ESRD (after the 30 month coordination period)

C. When either you or a covered family member are eligible for Medicare solely due to

disability and you...

1) Have FEHB coverage on your own as an active employee or through a family member who

is an active employee

2) Have FEHB coverage on your own as an annuitant or through a family member who is an

annuitant

D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.

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When you are age 65 or over and do not have Medicare

Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those payments you would be

entitled to if you had Medicare. Your physician and hospital must follow Medicare rules and cannot bill you for more than they could

bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital care and non-physician-based

care are not covered by this law; regular Plan benefits apply. The following chart has more information about the limits.

If you:

•are age 65 or over; and

•do not have Medicare Part A, Part B, or both; and

•have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and

•are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care:

•The law requires us to base our payment on an amount – the “equivalent Medicare amount” – set by Medicare’s rules for what

Medicare would pay, not on the actual charge.

•You are responsible for your deductible, coinsurance, or copayments under this Plan.

•You are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation

of benefits (EOB) form that we send you.

•The law prohibits a hospital from collecting more than the equivalent Medicare amount.

And, for your physician care, the law requires us to base our payment and your applicable coinsurance or copayment on:

•an amount set by Medicare and called the “Medicare-approved amount,” or

•the actual charge if it is lower than the Medicare-approved amount.

If your physician: Participates with Medicare or accepts Medicare assignment for the claim and is in our Preferred network

Then you are responsible for: your deductibles, coinsurance, and copayments.

If your physician: Participates with Medicare and is not in our Preferred network

Then you are responsible for: all charges.

If your physician: Does not participate with Medicare and is in our Preferred network

Then you are responsible for: your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare-approved

amount.

Note: In many cases, your payment will be less because of our Preferred agreements. Contact your Local Plan for information about

what your specific Preferred provider can collect from you.

If your physician: Does not participate with Medicare and is not a member in our Preferred network

Then you are responsible for: all charges.

If your physician: Opts-out of Medicare via private contract and is in our Preferred network

Then you are responsible for: your deductibles, coinsurance, copayments, and any balance your physician charges.

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect

only up to the Medicare-approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or

hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than

allowed, ask for a refund. If you need further assistance, call us.

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A physician may have opted-out of Medicare and may or may not ask you to sign a private contract

agreeing that you can be billed directly for services ordinarily covered by Original Medicare. This is

different than a Non-participating doctor, and we recommend you ask your physician if they have

opted-out of Medicare. Should you visit an opt-out physician, the physician will not be limited to 115%

of the Medicare-approved amount. You may be responsible for paying the difference between the billed

amount and our regular in-network/out-of-network benefits.

Physicians Who Opt-

Out of Medicare

We limit our payment to an amount that supplements the benefits that Medicare would pay under

Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), regardless of whether

Medicare pays.

Note: We pay our regular benefits for emergency services to a facility provider, such as a hospital, that

does not participate with Medicare and is not reimbursed by Medicare.

We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when

the MRA statement is submitted to determine our payment for covered services provided to you if

Medicare is primary, when Medicare does not pay the VA facility.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both

Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the

claim.

You must see Preferred providers in order to receive benefits. See page 18 for the exceptions to this

requirement.

• If your physician accepts Medicare assignment, you pay nothing for covered charges.

• If your physician does not accept Medicare assignment, you pay the difference between the

“limiting charge” or the physician’s charge (whichever is less) and our payment combined with

Medicare’s payment.

It is important to know that a physician who does not accept Medicare assignment may not bill you for

more than 115% of the amount Medicare bases its payment on, called the “limiting charge.” The

Medicare Summary Notice (MSN) form that you receive from Medicare will have more information

about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician

to reduce the charges. If the physician does not, report the physician to the Medicare carrier that sent

you the MSN form. Call us if you need further assistance.

When you have the

Original Medicare

Plan (Part A, Part B,

or both)

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Please review the following table illustrating your cost-share liabilities when Medicare is your primary payor and your provider is in

our network and participates with Medicare compared to what you pay without Medicare. Please do not rely on this chart alone but

read all information in this section of the brochure. You can find more information about how our Plan coordinates with Medicare in

our

Medicare and You Guide for Federal Employees

available online at www.fepblue.org.

Benefit Description: Deductible

FEP Blue Focus You Pay Without Medicare Parts A & B: $500-Self, $1,000-Family

FEP Blue Focus You Pay With Medicare Parts A & B: $0.00

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum

FEP Blue Focus You Pay Without Medicare Parts A & B: $8,500-Self, $17,000-Family

FEP Blue Focus You Pay With Medicare Parts A & B: $8,500-Self, $17,000-Family

Benefit Description: Part B Premium Reimbursement

FEP Blue Focus You Pay Without Medicare Parts A & B: N/A

FEP Blue Focus You Pay With Medicare Parts A & B: N/A

Benefit Description: Primary Care Physician

FEP Blue Focus You Pay Without Medicare Parts A & B: $10 or 30%

FEP Blue Focus You Pay With Medicare Parts A & B: $0.00

Benefit Description: Specialist

FEP Blue Focus You Pay Without Medicare Parts A & B: $10 or 30%

FEP Blue Focus You Pay With Medicare Parts A & B: $0.00

Benefit Description: Inpatient Hospital

FEP Blue Focus You Pay Without Medicare Parts A & B: 30%

FEP Blue Focus You Pay With Medicare Parts A & B: $0.00

Benefit Description: Outpatient Hospital

FEP Blue Focus You Pay Without Medicare Parts A & B: 30%

FEP Blue Focus You Pay With Medicare Parts A & B: $0.00

Benefit Description: Incentives Offered

FEP Blue Focus You Pay Without Medicare Parts A & B: N/A

FEP Blue Focus You Pay With Medicare Parts A & B: N/A

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Section 10. Definitions of Terms We Use in This Brochure

An injury caused by an external force or element such as a blow or fall that requires immediate medical

attention, including animal bites and poisonings. Note: Injuries to the teeth while eating are not

considered accidental injuries. Dental care for accidental injury is limited to dental treatment necessary

to repair sound natural teeth.

Accidental injury

The period from entry (admission) as an inpatient into a hospital (or other covered facility) until

discharge. In counting days of inpatient care, the date of entry and the date of discharge count as the

same day.

Admission

Receiving information on the types of life-sustaining treatments that are available, completing advance

directives and other standard forms, and/or if you are diagnosed with a terminal illness and making

decisions about the care you would want to receive if you become unable to speak for yourself.

Advanced care

planning

Medications and other substances or products given by mouth, inhaled, placed on you, or injected in

you to diagnose, evaluate, and/or treat your condition. Agents include medications and other substances

or products necessary to perform tests such as bone scans, cardiac stress tests, CT scans, MRIs, PET

scans, lung scans, and X-rays, as well as those injected into the joint.

Agents

An authorization by the enrollee or spouse for us to issue payment of benefits directly to the provider.

We reserve the right to pay you, the enrollee, directly for all covered services. Benefits provided under

the contract are not assignable by the member to any person without express written approval of the

Carrier, and in the absence of such approval, any such assignment shall be void.

Please visit www.fepblue.org to obtain a valid authorization form.

Assignment

Reproductive services, testing, and treatments involving manipulation of eggs, sperm, and embryos to

achieve pregnancy. In general, assisted reproductive technology (ART) procedures are used to retrieve

eggs from a woman, combine them with sperm in the laboratory, and then implant the embryos or

donate them to another woman.

Assisted reproductive

technology (ART)

A complex drug or product that is manufactured in a living organism, or its components, that is used as

a diagnostic, preventive or therapeutic agent.

Biologic drug

A U.S. FDA-approved biologic drug, which is considered highly similar to an original brand-name

biologic drug, with no clinically meaningful differences from the original biologic drug in terms of

safety, purity and potency.

Biosimilar drug

A U.S. FDA-approved biosimilar drug that may be automatically substituted for the original brand-

name biologic drug.

Biosimilar,

interchangeable drug

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the

effective date of their enrollment and ends on December 31 of the same year.

Calendar year

The Blue Cross and Blue Shield Association, on behalf of the local Blue Cross and Blue Shield Plans. Carrier

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is

conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening

disease or condition, and is either Federally funded; conducted under an investigational new drug

application reviewed by the U.S. Food and Drug Administration (U.S. FDA); or is a drug trial that is

exempt from the requirement of an investigational new drug application.

Clinical trials

See Section 4 page 28. Coinsurance

A claim for continuing care or an ongoing course of treatment that is subject to prior approval. See page

26 in Section 3.

Concurrent care

claims

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A condition that existed at or from birth and is a significant deviation from the common form or norm.

Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birth marks;

ambiguous genitalia; and webbed fingers and toes. Note: Congenital anomalies do not include

conditions related to the teeth or intra-oral structures supporting the teeth.

Congenital anomaly

See Section 4 page 28. Copayment

Benefits under FEP Blue Focus that have no or a low copayment. CORE benefits are not subject to

deductible or coinsurance. The benefits are most commonly used to receive general care and to

maintain your overall health and well-being, but also include coverage for spinal manipulations,

acupuncture and accidental injury.

Core benefits

Any surgical procedure or any portion of a procedure performed primarily to improve physical

appearance through change in bodily form, except for repair of accidental injury, or to restore or correct

a part of the body that has been altered as a result of disease or surgery or to correct a congenital

anomaly.

Cosmetic surgery

See Section 4 page 28. Cost-sharing

Services we provide benefits for, as described in this brochure. Covered services

Facility-based care that does not require access to the full spectrum of services performed by licensed

healthcare professionals that is available 24 hours a day in acute inpatient hospital settings to avoid

imminent, serious, medical or psychiatric consequences. By “facility-based,” we mean services

provided in a hospital, long term care facility, extended care facility, skilled nursing facility, residential

treatment center, school, halfway house, group home, or any other facility providing skilled or unskilled

treatment or services to individuals whose conditions have been stabilized. Custodial or long term care

can also be provided in the patient’s home, however defined.

Custodial or long term care may include services that a person not medically skilled could perform

safely and reasonably with minimal training, or that mainly assist the patient with daily living activities,

such as:

1. Personal care, including help in walking, getting in and out of bed, bathing, eating (by spoon, tube,

or gastrostomy), exercising, or dressing;

2. Homemaking, such as preparing meals or special diets;

3. Moving the patient;

4. Acting as companion or sitter;

5. Supervising medication that can usually be self-administered; or

6. Treatment or services that any person can perform with minimal instruction, such as recording

pulse, temperature, and respiration; or administration and monitoring of feeding systems.

We do not provide benefits for custodial or long term care, regardless of who recommends the care or

where it is provided. The Carrier, its medical staff, and/or an independent medical review determine

which services are custodial or long term care.

Custodial or long

term care

Equipment and supplies that are:

1. Prescribed by your physician (i.e., the physician who is treating your illness or injury);

2. Medically necessary;

3. Primarily and customarily used only for a medical purpose;

4. Generally useful only to a person with an illness or injury;

5. Designed for prolonged use; and

6. Used to serve a specific therapeutic purpose in the treatment of an illness or injury.

Durable medical

equipment

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Experimental or investigational shall mean:

1. A drug, device, or biological product that cannot be lawfully marketed without approval of the U.S.

Food and Drug Administration (U.S. FDA); and approval for marketing has not been given at the

time it is furnished; or

2. Reliable evidence shows that the healthcare service (e.g., procedure, treatment, supply, device,

equipment, drug, biological product) is the subject of ongoing phase I, II, or III clinical trials or

under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its

efficacy as compared with the standard means of treatment or diagnosis; or

3. Reliable evidence shows that the consensus of opinion among experts regarding the healthcare

service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) is that

further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity,

its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis;

4. Reliable evidence shows that the healthcare service (e.g., procedure, treatment, supply, device,

equipment, drug, biological product) does not improve net health outcome, is not as beneficial as

any established alternatives, or does not produce improvement outside of the research setting.

Reliable evidence shall mean only evidence published in peer-reviewed medical literature generally

recognized by the relevant medical community and physician specialty society recommendations, such

as:

1. Published reports and articles in the authoritative medical and scientific literature;

2. The written protocol or protocols used by the treating facility or the protocol(s) of another facility

studying substantially the same drug, device, or biological product or medical treatment or

procedure; or

3. The written informed consent used by the treating facility or by another facility studying

substantially the same drug, device, or biological product or medical treatment or procedure.

Experimental or

investigational

services

A generic alternative is a U.S. FDA-approved generic drug in the same class or group of drugs as your

brand-name drug. The therapeutic effect and safety profile of a generic alternative are similar to your

brand-name drug, but it has a different active ingredient.

Generic alternative

A generic equivalent is a drug whose active ingredients are identical in chemical composition to those

of its brand-name counterpart. Inactive ingredients may not be the same. A generic drug is considered

“equivalent,” if it has been approved by the U.S. FDA as interchangeable with your brand-name drug.

Generic equivalent

Healthcare coverage that you are eligible for based on your employment, or your membership in or

connection with a particular organization or group, that provides payment for medical services or

supplies, or that pays a specific amount of more than $200 per day for hospitalization (including

extension of any of these benefits through COBRA).

Group health

coverage

A physician or other healthcare professional licensed, accredited, or certified to perform specified

health services consistent with state law. See page 16 for information about how we determine which

healthcare professionals are covered under this Plan.

Healthcare

professional

A questionnaire designed to assess your overall health and identify potential health risks. Service

Benefit Plan members have access to the Blue Cross and Blue Shield HRA (called the “Blue Health

Assessment”) which is supported by a computerized program that analyzes your health and lifestyle

information and provides you with a personal and confidential health action plan that is protected by

HIPAA privacy and security provisions. Results from the Blue Health Assessment include practical

suggestions for making healthy changes and important health information you may want to discuss with

your healthcare provider. For more information, visit our website, www.fepblue.org.

Health Risk

Assessment (HRA)

You are an inpatient when you are formally admitted to a hospital with a doctor’s order.

Note: Inpatient care requires precertification. For some services and procedures prior approval must

also be obtained. See page 19.

Inpatient

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A comprehensive, structured outpatient treatment program that includes extended periods of individual

or group therapy sessions designed to assist members with mental health and/or substance

use disorders. It is an intermediate setting between traditional outpatient therapy and partial

hospitalization, typically performed in an outpatient facility or outpatient professional office setting.

Program sessions may occur more than one day per week. Timeframes and frequency will vary based

upon diagnosis and severity of illness.

Intensive outpatient

care

A Blue Cross and/or Blue Shield Plan that serves a specific geographic area. Local Plan

The term medical food, as defined in Section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) is

“a food which is formulated to be consumed or administered enterally under the supervision of a

physician and which is intended for the specific dietary management of a disease or condition for which

distinctive nutritional requirements, based on recognized scientific principles, are established by

medical evaluation.” In general, to be considered a medical food, a product must, at a minimum, meet

the following criteria: the product must be a food for oral or tube feeding; the product must be labeled

for the dietary management of a specific medical disorder, disease, or condition for which there are

distinctive nutritional requirements; and the product must be intended to be used under medical

supervision.

Medical foods

All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable

only when we determine that the criteria for medical necessity are met. Medical necessity shall mean

healthcare services that a physician, hospital, or other covered professional or facility provider,

exercising prudent clinical judgment, would provide to a patient for the purpose of preventing,

evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice in the United States; and

2. Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered

effective for the patient’s illness, injury, disease, or its symptoms; and

3. Not primarily for the convenience of the patient, physician, or other healthcare provider, and not

more costly than an alternative service or sequence of services at least as likely to produce

equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness,

injury, or disease, or its symptoms; and

4. Not part of or associated with scholastic education or vocational training of the patient; and

5. In the case of inpatient care, able to be provided safely only in the inpatient setting.

For these purposes, “generally accepted standards of medical practice” means standards that are based

on credible scientific evidence published in peer-reviewed medical literature generally recognized by

the relevant medical community and physician specialty society recommendations.

The fact that one of our covered physicians, hospitals, or other professional or facility providers

has prescribed, recommended, or approved a service or supply does not, in itself, make it

medically necessary or covered under this Plan.

Medical necessity

Under the telehealth benefit, you have on-demand access to care for common, non-emergent conditions.

Examples of common conditions include sinus problems, rashes, allergies, cold and flu symptoms, etc.

Minor acute

conditions

Errors in medical care that are clearly identifiable, preventable, and serious in their consequences, such

as surgery performed on a wrong body part, and specific conditions that are acquired during your

hospital stay, such as severe bed sores. For more information, see page 7.

Never Events

Medical services covered under FEP Blue Focus NON-CORE benefits are subject to the deductible and

coinsurance. These services include hospitalization, surgery, transplant coverage, etc.

Non-Core benefits

Although you may stay overnight in a hospital room and receive meals and other hospital services,

some services and overnight stays – including “observation services” – are actually outpatient care.

Observation care includes care provided to members who require significant treatment or monitoring

before a physician can decide whether to admit them on an inpatient basis, or discharge them to home.

The provider may need 6 to 24 hours or more to make that decision.

Observation services

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If you are in the hospital more than a few hours, always ask your physician or the hospital staff if your

stay is considered inpatient or outpatient.

You are an outpatient if you are getting emergency department services, observation services, outpatient

surgery, lab tests, X-rays, or any other hospital services, and the doctor has not written an order to admit

you to a hospital as an inpatient. In these cases, you are an outpatient even if you are admitted to a room

in the hospital for observation and spend the night at the hospital.

Outpatient

Our Plan allowance is the amount we use to determine our payment and your cost-share for covered

services. Fee-for-service plans determine their allowances in different ways. If the amount your

provider bills for covered services is less than our allowance, we base your share (coinsurance,

deductible, and/or copayments), on the billed amount. We determine our allowance as follows:

• PPO providers (Preferred provider) – Our allowance (which we may refer to as the “PPA” for

“Preferred Provider Allowance”) is the negotiated amount that Preferred providers (hospitals and

other facilities, physicians, and other covered healthcare professionals that contract with each local

Blue Cross and Blue Shield Plan, and retail pharmacies that contract with CVS Caremark) have

agreed to accept as payment in full, when we pay primary benefits.

Our PPO allowance includes any known discounts that can be accurately calculated at the time your

claim is processed. For PPO facilities, we sometimes refer to our allowance as the “Preferred rate.”

The Preferred rate may be subject to a periodic adjustment after your claim is processed that may

decrease or increase the amount of our payment that is due to the facility. However, your cost-

sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the

decrease to the reserves of this Plan. If our payment amount is increased, we pay that cost on your

behalf.

• Participating providers (Non-preferred provider) – Our allowance (which we may refer to as the

“PAR” for “Participating Provider Allowance”), applied when a service is paid due to an exception

listed on page 18, is the negotiated amount that these providers (hospitals and other facilities,

physicians, and other covered healthcare professionals that contract with some local Blue Cross and

Blue Shield Plans) have agreed to accept as payment in full, when we pay primary benefits. For

facilities, we sometimes refer to our allowance as the “Member rate.” The Member rate includes

any known discounts that can be accurately calculated at the time your claim is processed, and may

be subject to a periodic adjustment after your claim is processed that may decrease or increase the

amount of our payment that is due to the facility. However, your cost-sharing (if any) does not

change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of

this Plan. If our payment amount is increased, we pay that cost on your behalf.

• Non-participating providers (Non-preferred provider) – We have no agreements with these

providers to limit what they can bill you for their services. This means that using Non-participating

providers for exceptions listed on page 18 could result in your having to pay significantly greater

amounts for the services you receive. We determine our allowance as follows:

- For inpatient services at hospitals, and other facilities that do not contract with your local Blue

Cross and Blue Shield Plan (“Non-member facilities”), our allowance is based on the Local Plan

Allowance. The Local Plan Allowance varies by region and is determined by each Plan. If you

would like additional information, or to obtain the current allowed amount, please call the

customer service phone number on the back of your ID card. For inpatient stays resulting from

medical emergencies or accidental injuries, or for emergency deliveries, our allowance is the

lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance

with federal laws and regulations;

- For outpatient services resulting from a medical emergency or accidental injury that are billed by

Non-member facilities, our allowance is the lesser of the billed amount or the qualifying payment

amount (QPA) determined in accordance with federal laws and regulations (minus any amount

for noncovered services);

Plan allowance

132 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 10

- For physicians and other covered healthcare professionals that do not contract with your local

Blue Cross and Blue Shield Plan, our allowance is equal to the greater of (1) the Medicare

participating fee schedule amount or the Medicare Part B Drug Average Sale Price (ASP) for the

service, drug, or supply in the geographic area in which it was performed or obtained or (2) 100%

of the Local Plan Allowance. In the absence of a Medicare participating fee schedule amount or

ASP for any service, drug, or supply, our allowance is the Local Plan Allowance. Contact your

Local Plan if you need more information. We may refer to our allowance for Non-participating

providers as the “NPA” (for “Non-participating Provider Allowance”);

- For non-emergency medical services performed in Preferred hospitals provided by physicians and

other covered healthcare professionals identified under the NSA (see page 29) that do not

contract with your local Blue Cross and Blue Shield Plan and cannot balance bill you under this

regulation, our allowance is equal to the lesser of the billed amount or the qualifying payment

amount (QPA) determined in accordance with federal laws and regulations;

- For emergency medical and mental health and substance use disorders services performed in the

emergency department of a hospital provided by physicians and other covered healthcare

professionals, and air ambulance providers that do not contract with your local Blue Cross and

Blue Shield Plan, our allowance is equal to the lesser of the billed amount or the qualifying

payment amount (QPA) determined in accordance with federal laws and regulations;

- For services you receive outside of the United States, Puerto Rico, and the U.S. Virgin Islands

from providers that do not contract with us or with the Overseas Assistance Center (provided by

GMMI), we use our Overseas Fee Schedule to determine our allowance. Our fee schedule is

based on a percentage of the amounts we allow for Non-participating providers in the

Washington, D.C., area, or a customary percent of billed charge, whichever is higher.

Note: Using Non-participating or Non-member providers (Non-preferred) when an exception is

granted (see page 18) could result in your having to pay significantly greater amounts for the

services you receive. Non-participating and Non-member providers are under no obligation to accept

our allowance as payment in full. If you use Non-participating and/or Non-member providers, you will

be responsible for any difference between our payment and the billed amount (except in certain

circumstances involving covered Non-participating professional care – see below). In addition, you will

be responsible for any applicable deductible, coinsurance, or copayment. You can reduce your out-of-

pocket expenses by using Preferred providers whenever possible. To locate a Preferred provider, visit

www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer

service phone number on the back of your ID card. We encourage you to always use Preferred providers

for your care.

Note: For certain covered services from Non-participating professional providers, your responsibility

for the difference between the Non-participating Provider Allowance (NPA) and the billed amount may

be limited. See page 29,

Important Notice About Surprise Billing

Important notice

about using Non-

participating

providers!

(These providers are

only covered on an

exception basis)

Any claims that are not pre-service claims. In other words, post-service claims are those claims where

treatment has been performed and the claims have been sent to us in order to apply for benefits.

Post-service claims

The requirement to contact the local Blue Cross and Blue Shield Plan serving the area where the

services will be performed before being admitted for inpatient care. Please refer to the precertification

information listed in Section 3.

Precertification

An arrangement between Local Plans and physicians, hospitals, healthcare institutions, and other

covered healthcare professionals (or for retail pharmacies, between pharmacies and CVS Caremark) to

provide services to you at a reduced cost. The PPO provides you with an opportunity to reduce your

out-of-pocket expenses for care by selecting your facilities and providers from among a specific group.

PPO providers are available in most locations; using them whenever possible helps contain healthcare

costs and reduces your out-of-pocket costs. The selection of PPO providers is solely the Local Plan’s

(or for pharmacies, CVS Caremark’s) responsibility. We cannot guarantee that any specific provider

will continue to participate in these PPO arrangements.

Preferred provider

organization (PPO)

arrangement

133 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Those claims (1) that require precertification or prior approval, and (2) where failure to obtain

precertification or prior approval results in a reduction of benefits.

Pre-service claims

Adult preventive care includes the following services: preventive office visits and exams (including

health screening services: to measure height, weight, blood pressure, heart rate, and Body Mass Index

(BMI)); general health panel; basic or comprehensive metabolic panel; fasting lipoprotein profile;

urinalysis; CBC; screening for diabetes mellitus, hepatitis B and hepatitis C, and latent tuberculosis;

screening for alcohol/substance use disorders; counseling on reducing health risks; screening for

depression; screening for chlamydia, syphilis, gonorrhea, HPV, and HIV; screening for intimate partner

violence for women of reproductive age; administration and interpretation of a Health Risk Assessment

questionnaire; cancer screenings including low-dose CT screening for lung cancer; screening for

abdominal aortic aneurysms; and osteoporosis screening, as specifically stated in this brochure; and

immunizations as licensed by the U.S. Food and Drug Administration (U.S. FDA). Note: Anesthesia

services and pathology services associated with preventive colorectal surgical screenings are also paid

as preventive care.

Preventive care,

adult

Written assurance that benefits will be provided by:

1. The Local Plan where the services will be performed; or

2. The Retail Pharmacy Program or the Specialty Drug Pharmacy Program.

For more information, see the benefit descriptions in Section 5 and

Other services

in Section 3, under

You need prior Plan approval for certain services

, on pages 19-22.

Prior approval

A Carrier’s pursuit of a recovery if a covered individual has suffered an illness or injury and has

received, in connection with that illness or injury, a payment from any party that may be liable, any

applicable insurance policy, or a workers’ compensation program or insurance policy, and the terms of

the Carrier’s health benefits plan require the covered individual, as a result of such payment, to

reimburse the Carrier out of the payment to the extent of the benefits initially paid or provided. The

right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Reimbursement

The act of returning to the country of birth, citizenship or origin. Repatriation

Services that are not related to a specific illness, injury, set of symptoms, or maternity care (other than

those routine costs associated with a clinical trial as defined on page 128).

Routine services

An examination or test of an individual with no signs or symptoms of the specific disease for which the

examination or test is being done, to identify the potential for that disease and prevent its occurrence.

Screening service

A tooth that is whole or properly restored (restoration with amalgams or resin-based composite fillings

only); is without impairment, periodontal, or other conditions; and is not in need of the treatment

provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously

restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered

a sound natural tooth.

Sound natural tooth

Pharmaceutical products that are included on the FEP Blue Focus Specialty Drug List that are typically

high in cost and have one or more of the following characteristics:

• Injectable, infused, inhaled, or oral therapeutic agents, or products of biotechnology

• Complex drug therapy for a chronic or complex condition, and/or high potential for drug adverse

effects

• Specialized patient training on the administration of the drug (including supplies and devices

needed for administration) and coordination of care is required prior to drug therapy initiation and/

or during therapy

• Unique patient compliance and safety monitoring requirements

• Unique requirements for handling, shipping, and storage

Specialty drugs

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A Carrier’s pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a

workers’ compensation program or insurance policy, as successor to the rights of a covered individual

who suffered an illness or injury and has obtained benefits from the Carrier’s health benefits plan.

Subrogation

Under the telehealth benefit, dermatologic conditions seen and treated include but are not limited to

acne, dermatitis, eczema, psoriasis, rosacea, seborrheic keratosis, fungal infections, scabies, suspicious

moles, and warts. Members capture important digital images, combine those with the comprehensive

questionnaire responses, and send those to the dermatology network without requiring a phone or video

interaction.

Telehealth

dermatology

Non-emergency services provided by phone or secure online video/messaging for minor acute

conditions (see page 131 for definition), dermatology care, behavioral health and substance use disorder

counseling, and nutritional counseling. Go to www.fepblue.org/telehealth or call 855-636-1579, TTY:

855-636-1578, toll free to access this benefit. After your telehealth visit, please follow up with your

primary care provider or specialist.

Telehealth services

Services provided by phone or secure online video/messaging for evaluation and management services.

This does not include the use of fax machine or email; costs associated with enabling or maintaining

providers’ telehealth (telemedicine) technologies; or fees for asynchronous services—medical

information stored and forwarded to be reviewed at a later time by a physician or healthcare practitioner

at a distant site without the patient being present. Providers must perform covered services acting

within the scope of their license or certification under applicable state law. Please note, your healthcare

provider must know when and where they can treat you. You, in turn, are responsible for accurately

identifying to your provider where you are physically located for the service you received through

telehealth (telemedicine) technologies. You and your physician must be in the same U.S. State,

Territory, or foreign country as required by applicable legislation.

Telemedicine services

A defined number of consecutive days associated with a covered organ/tissue transplant procedure. Transplant period

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for

non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;

• Waiting could seriously jeopardize your ability to regain maximum function; or

• In the opinion of a physician with knowledge of your medical condition, waiting would subject you

to severe pain that cannot be adequately managed without the care or treatment that is the subject of

the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will judge

whether a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses

an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our customer service

department using the phone number on the back of your ID card and tell us the claim is urgent. You

may also prove that your claim is an urgent care claim by providing evidence that a physician with

knowledge of your medical condition has determined that your claim involves urgent care.

Urgent care claims

“Us,” “we,” and “our” refer to the Blue Cross and Blue Shield Service Benefit Plan, and the local Blue

Cross and Blue Shield Plans that administer it.

Us/We/Our

FEP Blue Focus WRAP benefits are not subject to the deductible and have either a different copayment

than the copayment applied under the CORE benefits (i.e., $25 for the combined 25 visits for physical

therapy) or a different coinsurance level than the coinsurance applied under the NON-CORE benefits

(i.e., brand-name preferred drugs are paid at 40% of the Plan allowance up to $350 per 30-day

prescription).

Wrap benefits

135 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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“You” and “your” refer to the enrollee (the contract holder eligible for enrollment and coverage under

the Federal Employees Health Benefits Program and enrolled in the Plan) and each covered family

member.

You/Your

136 2022 Blue Cross® and Blue Shield® Service Benefit Plan

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Section 10

Index

Do not rely only on this page; it is for your convenience and may not show all pages where the terms appear. This Index is not an

official statement of benefits.

Abortion ....................45-47, 71-73, 111-112

Accidental injury ..........................80-83, 101

Acupuncture ....................................55, 73-76

Affordable Care Act (ACA) ...................9, 12

Allergy care ................................................48

Allogeneic transplants ..........................63-68

Alternative treatments ................................55

Ambulance ......................................19-22, 80

Ambulatory surgical center ..........73-76, 100

Anesthesia .........................45-47, 70-76, 102

Angiographies ...........................40-41, 73-76

Appeals .......................................27, 115-118

Applied behavior analysis (ABA) ...19-22,

49, 73-76, 111-112

Assistant surgeon .......................................18

Autism spectrum disorder ...49, 73-76,

111-112

Autologous transplants .........................61-68

Biopsies ..........................41-44, 57-59, 73-76

Birthing centers ........17-18, 24, 45-47, 70-73

Blood and blood plasma .................54, 73-76

Blood or marrow stem cell ...19-22, 49,

61-68

Blue Distinction Centers .......................17-18

for Transplants .....................19-22, 66-68

Blue Distinction Specialty Care ...........17-22

Blue Health Assessment .......41-44, 103, 130

Bone density tests ......................40-41, 73-76

Brand-name drugs ...............................93-100

BRCA ........................................19-22, 40-44

Breast pump and supplies .....................45-47

Breast reconstruction ............................59-61

Breast prostheses and surgical bras ......52

Breastfeeding support and supplies ...45-47,

71-73

Cancer tests .........................................41-44

Cardiac rehabilitation ..........19-22, 49, 73-76

Cardiovascular monitoring ........40-41, 73-76

Care Management Programs ....................104

Case management ....................................104

Casts ...............................57-59, 70-71, 73-76

Catastrophic protection .......30, 126-127, 141

Cervical cancer screening .....................41-45

CHAMPVA .......................................119-120

Changes for 2021 .......................................15

Chemotherapy .....................49, 66-68, 73-76

Children’s Equity Act ...........................10-11

Chiropractic manipulative treatment ...49, 55

Cholesterol tests ....................................40-44

Circumcision ..................45-47, 57-59, 71-73

Claims and claims filing

Overseas ................................30, 108-109

Post-service ...........26, 113-114, 116, 133

Pre-service ........................19, 26-27, 134

Clinic visits ....................39-40, 73-76, 85-86

Clinical trials ......19-22, 63-65, 121-122, 128

Cognitive rehabilitation ..........50, 73-77, 113

Coinsurance ................................28, 107, 128

Colonoscopy ..................41-44, 57-59, 73-76

Colorectal cancer tests

Colonoscopy ............41-44, 57-59, 73-76

Fecal occult blood test ....................41-44

Sigmoidoscopy ...............................41-44

Confidentiality ......................................13-14

Congenital anomalies ........19-22, 57-59, 129

Consultations .............................39-40, 85-86

Contact lenses ...............................51-52, 110

Contraceptives ...................47, 73-76, 93-100

Coordination of benefits ...................119-127

Copayments ................................................28

CORE benefits ......................................34-37

Cosmetic surgery ..........................57-61, 129

Cost-share/cost-sharing ..............................28

Costs for covered services ....................28-31

Coverage information ..................................9

Covered facility providers ....................17-18

Covered professional providers .................16

CT scans ............................40-41, 73-76, 128

Custodial or long term care ......................129

Deductible .................................................28

Definitions ........................................128-136

Dental care ........................101-102, 110, 121

Diabetic education ..........................55, 73-76

Diabetic supplies

Diabetic Meter Program ...............93-100

Insulin pumps .................................53-54

Insulin, test strips, and lancets ......93-100

Needles and disposable syringes

...93-100

Diagnostic and treatment services ........39-40

Diagnostic tests .........................40-41, 85-88

Dialysis ................................49, 53-54, 73-76

Disease Management ...............................104

Disputed claims ...........................27, 116-118

Divorce .......................................................12

DNA analysis of stool samples .............41-44

Donor expenses .....................................66-68

Drugs (see: Prescription drugs)

Durable medical equipment ...53-54, 73-76,

129

Prosthetic devices ...19-22, 52, 70-71,

73-76

Educational classes and programs .........55

EEGs ..........................................40-41, 73-76

EKGs .........................................40-41, 73-76

Emergency ................18, 26, 80-84, 101, 107

Enrollment .............................9-10, 16, 18-19

Exception situations ...................................18

Exclusions .........................................111-112

Experimental or investigational ...61-63,

111-112, 130

Extended care benefits ...............................77

Eyeglasses .............................................51-52

Facility providers ................................17-18

Family planning .........................................47

Fecal occult blood test ..........................41-44

FEDVIP ......................................27, 101, 121

fepblue mobile application .......................106

fepblue.org ...................................................4

Flexible benefits option ............................105

Foot care .....................................................52

Formulary/Preferred drug list ....................91

Fraud .........................................................4-5

Gender affirming care ...19-22, 52, 56-59,

Generic drugs ......................................93-100

Generic equivalents ..............................89-90

Genetic screening/testing ...19-22, 40-41,

73-76

Health Insurance Marketplace ...............12

Health tools ..............................................103

Healthy Families ......................................103

Hearing aids and hearing services ........50-51

Home health services ............................54-55

Home nursing care (maternity) ...45-47,

54-55

Hospice care .........................................77-79

Hospital .................................................17-18

inpatient ....................70-71, 87, 102, 125

outpatient ..........................73-76, 88, 102

Human papillomavirus (HPV) tests ......41-45

Hypertension Management Program ...103-1-

Identification cards ..................................16

Immunizations .........................41-45, 93-100

Inpatient hospital benefits .....................70-71

Inpatient professional services ...39-40,

85-86

Insulin .................................................93-100

Insulin pumps .......................................53-54

Intensity-modulated radiation therapy

(IMRT) ............................................19-22, 49

Laboratory and pathology services ........18

Low-dose CT screening ...........................134

Mammograms .....................................41-44

Manipulative treatment ..............................55

Maternity care ...........................24, 26, 45-47

Maxillofacial surgery .................................61

Medicaid ..................................................120

Medical emergency .........................81, 83-84

Medical foods .......................54, 93-100, 131

Medical supplies ................54, 70-79, 93-100

Medically necessary ...19, 23, 26, 111-112,

131

Medicare ............................1, 23-24, 119-127

Medications and supplies ....................93-100

137 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Index

Medications to promote better health

...44-45,

93-100

Member facilities ..................................17-18

Mental health/substance use disorder ...85-88

MRIs ..................................40-41, 73-76, 128

Multiple procedures ..............................57-59

MyBlue Customer eService .....................104

National Doctor & Hospital Finder ......104

Neurological testing ..................40-41, 73-76

Never Events .....................................6-8, 131

Newborn care ...........26, 39-40, 44-47, 71-73

No Surprises Act (NSA) .......................29-30

NON-CORE benefits ............................34-37

Non-member facilities ..........................17-18

Non-participating providers ..........29-30, 133

Non-preferred providers .................16, 29-30

Nurse .........................................54-55, 77-79

Nutritional counseling ...39-45, 57-59, 70-73

Observation care .............................131-132

Obstetrical care ..........................45-47, 71-73

Occupational therapy ......................50, 73-79

Office visits ...............................39-40, 85-86

Online Health Coach (OHC) ....................103

Oral surgery ...............................................61

Organ/tissue transplants ...19-22, 61-63,

65-68

Orthopedic devices ..............52, 59-61, 73-76

Osteoporosis screening ............................134

Ostomy and catheter supplies ....................54

Out-of-pocket expenses .....................30, 133

Outpatient facility services ...........73-76, 102

Outpatient professional services ...39-40,

85-86

Overpayments ............................................31

Overseas Assistance Center .....................107

Overseas services, drugs, supplies and

claims ..........................................30, 107-109

Oxygen ......................................53-54, 70-79

Pap tests ...............................................41-45

Participating providers ..........................29-30

Patient Safety and Quality Monitoring

(PSQM) program ..................................89-90

Personal Health Record ............................103

PET scans ..........................40-41, 73-76, 128

Pharmacotherapy ............................39-40, 49

Physical examinations ...........73-76, 111-112

Physical therapy ..............................50, 73-79

Physician ....................16, 123, 126, 130, 133

Plan allowance ............................29, 132-133

PPO ....................................13-14, 17-18, 133

Pre-admission testing ............................70-71

Precertification ...19-22, 24-26, 56-57, 69,

76-77, 85, 87, 133-134

Preferred providers .................13-14, 16, 104

Pregnancy (see: Maternity care)

Prescription drugs

Brand-name drugs .........................93-100

Drugs from other sources ...................100

Generic drugs ................................93-100

Preferred retail pharmacies ...93-100, 114

Retail Pharmacy Program ...89-90,

108-109

Self-injectable drugs .....................93-100

Specialty Drug Pharmacy Program ...89--

90, 93-100, 114

Specialty drugs .....................93-100, 134

Preventive care

Adult .......................................41-44, 134

Child ...............................................44-45

Primary care provider (PCP) ......................34

Prior approval ...19-25, 40-44, 49, 53-54,

56-59, 61-63, 66-69, 73-80, 85-86,

89-90, 134

Professional providers ................................16

Prostate cancer ......................................41-44

Prosthetic devices ...52, 57-59, 70-71, 73-76

Psychotherapy .......................................85-88

Pulmonary rehabilitation ................49, 73-76

Radiation therapy .........................49, 73-76

Reconsiderations .........................27, 116-118

Replacement coverage ..........................11-12

Reproductive services ...................47-48, 128

Assisted reproductive technology (ART)

................................................47-48, 128

Residential treatment center (RTC) ...17-19,

24-26, 76-77, 87

Rights and responsibilities ....................13-14

Room and board ..................70-71, 76-77, 87

Routine Annual Physical Incentive Program

............................................................106

Screening services ..................................134

Second surgical opinion ........................39-40

Self-injectable drugs ...........................89-100

Skilled nursing facility (SNF) care ...77, 129

Smoking cessation ........................55, 93-100

Social worker ...........................................104

Specialty Drug Pharmacy Program ...93-100,

108-109, 114

Specialty drugs ...........................89-100, 134

Speech therapy ................................50, 73-79

Speech-generating devices ...................53-54

Stem cell transplants ..................19-22, 61-63

Sterilization procedures ..................47, 57-59

Subrogation ...............................120-121, 135

Substance use disorder ..........................85-88

Surgery ...................17-22, 51-52, 56-69, 129

Assistant surgeon .................................18

Eye: cataract, amblyopia, strabismus

........................................................57-59

Gender reassignment ...........19-24, 57-59

Multiple procedures ........................56-59

Oral and maxillofacial ..........................61

Outpatient ............................57-59, 73-76

Reconstructive .....................19-22, 59-61

Sterilization, reversal of voluntary ...47,

57-59

Surgical implants ......................52, 73-76

Surgical treatment of morbid obesity

.............................................19-22, 57-59

Transplants ..........................19-22, 61-68

Syringes ..............................................93-100

Telehealth

Dermatology ...........................39-40, 135

Mental health/substance use disorder

................................................85-86, 135

Minor acute conditions ...........39-40, 131

Nutritional counseling ............41-45, 105

Temporary Continuation of Coverage (TCC)

........................................................11-12

Tobacco cessation .........................55, 93-100

Transplants ..........................17-22, 49, 61-68

Travel benefit ................................66-68, 103

Treatment therapies ..............................49-50

TRICARE .........................................119-122

Ultrasounds ..............................40-41, 73-76

Urgent care center .................................82-84

Urgent care claims .............................25, 135

VA facility ................................................126

Vaccines ...................................41-45, 93-100

Verbal statements ...........................4, 27, 104

Vision services ......................................51-52

Waivers ......................................................29

Weight control ...........................19-22, 57-59

Wheelchairs ..........................................53-54

Wigs .....................................................37, 52

Workers’ compensation ............................120

WRAP benefits .....................................34-37

X-rays .......................................40-41, 73-76

138 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Index

Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP

Blue Focus – 2022

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 final decision, please read this FEHB brochure.

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 $500 per person ($1,000 per Self Plus One or Self and Family enrollment)

calendar year deductible. If you use a Non-PPO physician, benefits are not provided.

Benefits You Pay Page

Preferred provider: Nothing

Non-preferred (Participating/Non-participating): You pay all

charges

41-44 Medical services provided by physicians,

specialists and other healthcare

professionals: Preventive, adult

Preferred provider: Nothing

Non-preferred (Participating/Non-participating): You pay all

charges

44-45 Medical services provided by physicians,

specialists and other healthcare

professionals: Preventive, child

Preferred provider: $10 for the first 10 visits per calendar year

(combined medical and mental health and substance use

disorder)

After the 10th visit: 30%* of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating): You pay all

charges

39 Medical services provided by physicians,

specialists and other healthcare

professionals: Professional Visits

Preferred provider: 30%* of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating): You pay all

charges

39-40 Medical services provided by physicians,

specialists and other healthcare

professionals: Diagnostic and treatment services

provided in the office

Preferred Telehealth Provider: Nothing for the first 2 visits per

calendar year

After the 2nd visit: $10 copayment per visit

Non-preferred (Participating/Non-participating): You pay all

charges

39, 86 Medical services provided by physicians,

specialists and other healthcare

professionals: Telehealth services

Preferred: 30%* of the Plan allowance (deductible applies)

Non-preferred (Member/Non-member): You pay all charges

70-71 Services provided by a hospital: Inpatient

Preferred: 30%* of the Plan allowance (deductible applies)

Non-preferred (Member/Non-member): You pay all charges

73-76 Services provided by a hospital: Outpatient

139 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Summary

Benefits You Pay Page

Preferred: Nothing for outpatient hospital and physician

services within 72 hours (regular benefits apply thereafter)

Non-preferred:

• Participating: Nothing for outpatient hospital and physician

services within 72 hours (regular benefits thereafter)

• Non-participating: 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

82 Emergency benefits: Accidental injury

Professional, outpatient hospital:

Preferred urgent care: $25 copayment; PPO and Non-PPO

emergency room care: 30%* of our allowance (deductible

applies); Regular benefits for physician and hospital care*

provided in other than the emergency room/PPO urgent care

center

Maternity:

Ambulance transport services: 30%* of our allowance

(deductible applies)

Non-preferred (Participating/Non-participating) urgent care

center: You pay all charges

83 Emergency benefits: Medical emergency

Preferred provider: $10 for the first 10 visits per calendar year

(combined medical and mental health and substance use

disorder)

After the 10th visit: 30%* of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating): You pay all

charges

86 Emergency benefits: Mental health visits

Preferred provider: 30%* of the Plan allowance (deductible

applies)

Non-preferred (Participating/Non-participating): You pay all

charges

85-88 Mental health and substance use disorder

treatment (inpatient and outpatient)

Preferred retail pharmacy Tier 1 (generic): $5 copayment up to

a 30-day supply

Preferred retail pharmacy Tier 2 (brand name): 40%

coinsurance of the Plan allowance (up to a $350 maximum) for

up to a 30-day supply

Non-preferred pharmacy: You pay all charges

93 Prescription drugs: Retail Pharmacy Program

140 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Summary

Benefits You Pay Page

Preferred specialty pharmacy

Tier 2: 40% coinsurance of the Plan allowance (up to a $350

maximum) for up to a 30-day supply

98 Prescription drugs: Specialty Drug Pharmacy

Program

Treatment of an accidental dental injury within 72 hours

(regular benefits apply thereafter)

Preferred: Nothing

Non-Preferred:

• Participating: Nothing (no deductible)

• Non-participating: Any difference between our allowance

and the billed amount (no deductible)

101 Dental care

See Section 5(h). 103-106 Wellness and Other Special Features: Health

Tools; Blue Health Assessment; MyBlue

Customer eService; National Doctor and Hospital

Finder; Healthy Families; Travel Benefit/Services

Overseas; Care Management Programs; and

Routine Annual Physical Incentive Program

• Self Only: Nothing after $8,500 per contract per year

• Self Plus One: Nothing after $17,000 (PPO) per contract

per year

• Self and Family: Nothing after $17,000 per family per year

Notes:

• Some costs do not count toward this protection.

• 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.

30 Protection against catastrophic costs (your

catastrophic protection out-of-pocket maximum)

141 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

FEP Blue Focus Summary

2022 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums

or www.opm.gov/Tribalpremium.

Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution

is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your

Tribal Benefits Officer for exact rates.

Type of Enrollment Enrollment

Code

Premium Rate

Biweekly Monthly

Gov't

Your

Gov't

Your

Nationwide

FEP Blue Focus

Option Self Only

131 $159.44 $53.14 $345.44 $115.15

FEP Blue Focus

Option Self Plus

One

133 $342.77 $114.25 $742.66 $247.55

FEP Blue Focus

Option Self and

Family

132 $377.03 $125.67 $816.89 $272.29

142 2022 Blue Cross® and Blue Shield® Service Benefit Plan

FEP® Blue Focus

Rates