2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2023
Page 141
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus – 2023
Page 141
Prescription drugs: Specialty Drug Pharmacy Program
You pay:
Preferred specialty pharmacy
Tier 2: 40% coinsurance of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
Page(s): 98
Dental care
Treatment of an accidental dental injury within 72 hours (regular benefits apply thereafter)
You pay:
Preferred: Nothing
Non-Preferred:
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
You pay:
See Section 5(h).
Page(s): 103-106
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
You pay:
You pay:
Preferred specialty pharmacy
Tier 2: 40% coinsurance of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
Page(s): 98
Dental care
Treatment of an accidental dental injury within 72 hours (regular benefits apply thereafter)
You pay:
Preferred: Nothing
Non-Preferred:
- Participating: Nothing (no deductible)
- Non-participating: Any difference between our allowance and the billed amount (no deductible)
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
You pay:
See Section 5(h).
Page(s): 103-106
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
You pay:
- 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
- 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.