2026 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 19

 

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

 

What you must do to get covered care

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 4, 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, neonatologists, 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.

 

  • Transitional care
     
Specialty care: You may continue seeing your specialist and receiving any PPO benefits for up to 90 days if you are undergoing treatment for a chronic or disabling condition and you 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
  • we terminate our contract with your specialist for reasons other than for cause,
Contact us at the number on the back of your ID card or, if we drop out of the Program, contact your new plan.

If you are pregnant 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.

Note: If you lose access to your specialist because you changed your carrier or plan option enrollment, contact your new plan.

Sex-Trait Modification: If you are mid-treatment under this Plan, within a surgical or chemical regimen for Sex-Trait Modification for diagnosed gender dysphoria, for services for which you received coverage under the 2025 Plan brochure, you may seek an exception to continue care for that treatment. If you have questions about the exception process, contact us using the customer service phone number listed on the back of your ID card. If you disagree with our decision, please see Section 8 of this brochure for the disputed claims process. Individuals under age 19 are not eligible for exceptions related to services for ongoing surgical or hormonal treatment for diagnosed gender dysphoria.

 

  • If you are hospitalized when your enrollment begins
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.