2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 4. Your Costs for Covered Services
Page 30
 
Your costs for other care

Overseas care: We pay overseas claims at Preferred benefit levels. In most cases, our Plan allowance for professional provider services is based on our Overseas Fee Schedule. Most overseas professional providers are under no obligation to accept our allowance, and you must pay any difference between our payment and the provider’s bill. For inpatient facility care you receive overseas, we provide benefits in full for admissions to a Department of Defense (DoD) facility, or when the Overseas Assistance Center (provided by GMMI, Inc.) has arranged direct billing or acceptance of a guarantee of benefits with the facility. If a direct billing arrangement or guarantee of benefits is not accepted by the facility, you are responsible for the applicable deductible, copayment and/or coinsurance. For outpatient facility care you receive overseas, we provide benefits in full after you pay the applicable deductible and copayment or coinsurance. See Section 5(i) for more 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 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 $6,500 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 $13,000 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.

Carryover

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.