FEP Blue Focus^® for PSHB

Under FEP Blue Focus, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.

Cost sharing may not apply or may be different if Medicare is your primary coverage (it pays first).

• ^{^} What you’ll pay for a 30-day supply of covered drugs.
• ¹ Deductible applies. $500 for Self Only and $1,000 for Self + One and Self & Family.
• ² Specialty drugs are limited to a 30-day supply.
• ³ Professional charges for facility-based intensive outpatient treatment and professional charges for outpatient diagnostic tests to include psychological testing are not part of the 10 for $10 benefit.
• ⁴ Please see brochure for covered lab services.
• ⁵ You pay 30% of our allowance for agents, drugs and/or supplies you receive during your care.
• ⁶ You must be the contract holder or spouse, 18 or older, on a FEP Blue Focus plan to earn this reward.
• ⁷ The Annual Pharmacy Out-of-Pocket Maximum is inclusive of the cost of the prescription drug and what you pay out-of-pocket.
  
  
•  

The MPDP formulary and/or pharmacy network may change at any time. You will receive notice when necessary.

This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Plan’s federal brochure (RI 71-025). All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure.