2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 4. Your Costs for Covered Services
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments
Section 4. Your Costs for Covered Services
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments
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.
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.