Blue Cross and Blue Shield Service Benefit Plan Brochure - 2025

FEHB Standard and Basic Options

 

Document list

Document Name Document Number
Cover page FSB25.00.1.1
Inside cover FSB25.00.1.2
Table of Contents FSB25.00.1.3
Introduction FSB25.00.2.1
Plain Language FSB25.00.2.2
Stop Healthcare Fraud! FSB25.00.2.3
Discrimination is Against the Law FSB25.00.2.4
Preventing Medical Mistakes FSB25.00.2.5
No pre-existing condition limitation FSB25.00.3.1.1
Minimum essential coverage (MEC) FSB25.00.3.1.2
Minimum value standard FSB25.00.3.1.3
Where you can get information about enrolling in the FEHB Program FSB25.00.3.1.4
Enrollment types available for you and your family FSB25.00.3.1.5
Family member coverage FSB25.00.3.1.6
Children's Equity Act FSB25.00.3.1.7
When benefits and premiums start FSB25.00.3.1.8
When you retire FSB25.00.3.1.9
When FEHB coverage ends FSB25.00.3.2.1
Upon divorce FSB25.00.3.2.2
Temporary Continuation of Coverage (TCC) FSB25.00.3.2.3
Finding replacement coverage FSB25.00.3.2.4
Health Insurance Marketplace FSB25.00.3.2.5
Section 1. How This Plan Works FSB25.01.0
General features of our Standard and Basic Options//We have a Preferred Provider Organization (PPO) FSB25.01.1
How we pay professional and facility providers FSB25.01.2
Your rights and responsibilities FSB25.01.3
Your medical and claims records are confidential FSB25.01.4
Section 2. Changes for 2025 FSB25.02.0
Changes to our Standard Option only FSB25.02.1
Changes to our Basic Option only FSB25.02.2
Changes to both our Standard and Basic Options FSB25.02.3
Identification cards FSB25.03.1
Where you get covered care FSB25.03.2.0
Balance Billing Protection FSB25.03.2.05
Covered professional providers FSB25.03.2.1
Covered facility providers FSB25.03.2.2
What you must do to get covered care FSB25.03.3.0
Transitional care FSB25.03.3.1
If you are hospitalized when your enrollment begins FSB25.03.3.2
You need prior Plan Approval for certain services FSB25.03.4.00
Inpatient hospital, residential treatment center, or skilled nursing facility admission FSB25.03.4.01
Other services FSB25.03.4.02
Surgery by Non-participating providers under Standard Option FSB25.03.4.03
How to request precertification for an admission or get approval for Other services FSB25.03.4.04
Non-urgent care claims FSB25.03.4.05
Urgent care claims FSB25.03.4.06
Concurrent care claims FSB25.03.4.07
Emergency inpatient admission FSB25.03.4.08
Maternity care FSB25.03.4.09
If your facility stay needs to be extended FSB25.03.4.10
If your treatment needs to be extended FSB25.03.4.11
If you disagree with our pre-service claim decision FSB25.03.5.0
To reconsider a non-urgent care claim FSB25.03.5.1
To reconsider an urgent care claim FSB25.03.5.2
To file an appeal with OPM FSB25.03.5.3
Cost share/Cost-sharing FSB25.04.01
Copayment FSB25.04.02
Deductible FSB25.04.03
Coinsurance FSB25.04.04
If your provider routinely waives your cost FSB25.04.05
Waivers FSB25.04.06
Differences between our allowance and the bill FSB25.04.07
Important Notice About Surprise Billing — Know Your Rights FSB25.04.08
Your costs for other care FSB25.04.09
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments FSB25.04.10
Carryover FSB25.04.11
If we overpay you FSB25.04.12
When Government facilities bill us FSB25.04.13
The Federal Flexible Spending Account Program – FSAFEDS FSB25.04.14
Section 5. Benefits FSB25.05.01
Section 5. Standard and Basic Option Overview FSB25.05.02
Section 5(a). Overview FSB25.05a.0
Diagnostic and Treatment Services FSB25.05a.01
Lab, X-ray and Other Diagnostic Tests FSB25.05a.02
Preventive Care, Adult FSB25.05a.03
Preventive Care, Child FSB25.05a.04
Maternity Care FSB25.05a.05
Family Planning FSB25.05a.06
Reproductive Services FSB25.05a.07
Allergy Care FSB25.05a.08
Treatment Therapies FSB25.05a.09
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy FSB25.05a.10
Hearing Services (Testing, Treatment, and Supplies) FSB25.05a.11
Vision Services (Testing, Treatment, and Supplies) FSB25.05a.12
Foot Care FSB25.05a.13
Orthopedic and Prosthetic Devices FSB25.05a.14
Durable Medical Equipment (DME) FSB25.05a.15
Medical Supplies FSB25.05a.16
Home Health Services FSB25.05a.17
Manipulative Treatment FSB25.05a.18
Alternative Treatments FSB25.05a.19
Educational Classes and Programs FSB25.05a.20
Section 5(b). Overview FSB25.05b.0
Surgical Procedures FSB25.05b.1
Reconstructive Surgery FSB25.05b.2
Oral and Maxillofacial Surgery FSB25.05b.3
Organ/Tissue Transplants FSB25.05b.4
Anesthesia FSB25.05b.5
Section 5(c). Overview FSB25.05c.0
Inpatient Hospital FSB25.05c.1
Document Name Document Number
Outpatient Hospital or Ambulatory Surgical Center FSB25.05c.2
Blue Distinction Specialty Care FSB25.05c.3
Residential Treatment Center FSB25.05c.4
Extended Care Benefits/Skilled Nursing Care Facility Benefits FSB25.05c.5
Hospice Care FSB25.05c.6
Ambulance FSB25.05c.7
Section 5(d). Overview FSB25.05d.0
Accidental Injury FSB25.05d.1
Medical Emergency FSB25.05d.2
Ambulance FSB25.05d.3
Section 5(e). Overview FSB25.05e.0
Professional Services FSB25.05e.1
Inpatient Hospital or Other Covered Facility FSB25.05e.2
Residential Treatment Center FSB25.05e.3
Outpatient Hospital or Other Covered Facility FSB25.05e.4
Not Covered (Inpatient or Outpatient) FSB25.05e.5
Section 5(f). Overview FSB25.05f.0
There are important features you should be aware of FSB25.05f.01
Who can write your prescriptions FSB25.05f.02
Where you can obtain them FSB25.05f.03
What is covered FSB25.05f.04
Generic equivalents FSB25.05f.05
Disclosure of information FSB25.05f.06
These are the dispensing limitations FSB25.05f.07
Patient Safety and Quality Monitoring (PSQM) FSB25.05f.08
Prior Approval FSB25.05f.09
Standard Option Generic Incentive Program FSB25.05f.10
Medical Foods FSB25.05f.11
Here is how to obtain your prescription drugs and supplies FSB25.05f.12
Preferred Retail Pharmacies FSB25.05f.13
Non-preferred Retail Pharmacies FSB25.05f.14
Mail Service Prescription Drug Program FSB25.05f.15
Specialty Drug Pharmacy Program FSB25.05f.16
Asthma Medications FSB25.05f.17
Other Preferred Diabetic Medications, Test Strips, and Supplies FSB25.05f.18
Diabetic Meter Program FSB25.05f.19
Section 5(f). MPDP Overview FSB25.05f.20
MPDP There are important features you should be aware of FSB25.05f.21
MPDP Who can write your prescriptions FSB25.05f.22
MPDP Where you can obtain them FSB25.05f.23
MPDP What is covered FSB25.05f.24
MPDP Generic equivalents FSB25.05f.25
MPDP Disclosure of information FSB25.05f.26
MPDP These are the dispensing limitations FSB25.05f.27
MPDP Important Contact Information FSB25.05f.28
MPDP Prior Approval FSB25.05f.29
MPDP Medical Foods FSB25.05f.30
MPDP Here is how to obtain your prescription drugs and supplies FSB25.05f.31
MPDP Catastrophic Maximums FSB25.05f.32
MPDP Retail Pharmacies FSB25.05f.33
MPDP Mail Service Prescription Drug Program FSB25.05f.34
MPDP Asthma Medications FSB25.05f.35
MPDP Other Preferred Diabetic Medications, Test Strips, and Supplies FSB25.05f.36
Smoking and Tobacco Cessation Medications FSB25.05f.37
Anti-hypertensive Medications FSB25.05f.38
Over-the-counter (OTC) contraceptive drugs and devices FSB25.05f.39
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network FSB25.05f.40
Metformin and metformin extended release (excluding osmotic and modified release generic drugs) FSB25.05f.41
Medications to promote better health as recommended under the ACA FSB25.05f.42
Generic medications to reduce breast cancer risk for women FSB25.05f.43
Bowel preparation medications and antiretroviral therapy medications for HIV FSB25.05f.44
Opioid Reversal Agents: Tier 1 medications limited to generic naloxone spray and injectable FSB25.05f.45
Not Covered FSB25.05f.46
Drugs From Other Sources FSB25.05f.47
Section 5(g). Overview FSB25.05g.0
Accidental Injury Benefit FSB25.05g.1
Dental Benefits FSB25.05g.2
Health Tools FSB25.05h.01
Services for the Deaf and Hearing Impaired FSB25.05h.02
Web Accessibility for the Visually Impaired FSB25.05h.03
Travel Benefit/Services Overseas FSB25.05h.04
Healthy Families FSB25.05h.05
Diabetes Management Program FSB25.05h.06
Blue Health Assessment FSB25.05h.07
Hypertension Management Program FSB25.05h.08
Pregnancy Care Incentive Program FSB25.05h.09
Annual Incentive Limitation FSB25.05h.10
Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B FSB25.05h.11
MyBlue Customer eService FSB25.05h.12
National Doctor & Hospital Finder FSB25.05h.13
Care Management Programs FSB25.05h.14
Flexible Benefits Option FSB25.05h.15
Telehealth Services FSB25.05h.16
The fepblue Mobile Application FSB25.05h.17
Section 5(i). Services, Drugs, and Supplies Provided Overseas FSB25.05i.0
Non-FEHB Benefits Available to Plan Members FSB25.05N.0
Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover FSB25.06
Section 7. Filing a Claim for Covered Services FSB25.07
Section 8. The Disputed Claims Process FSB25.08
When you have other health coverage FSB25.09.1.0
TRICARE and CHAMPVA FSB25.09.1.1
Workers' Compensation FSB25.09.1.2
Medicaid FSB25.09.1.3
When other Government agencies are responsible for your care FSB25.09.2
When others are responsible for injuries FSB25.09.3
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) FSB25.09.4
Clinical trials FSB25.09.5
When you have Medicare FSB25.09.6.1
The Original Medicare Plan (Part A or Part B) FSB25.09.6.2
Tell us about your Medicare coverage FSB25.09.6.3
Document Name Document Number
Private contract with your physician FSB25.09.6.4
Medicare Advantage (Part C) FSB25.09.6.5
Medicare prescription drug coverage (Part D) FSB25.09.6.6
Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) FSB25.09.6.6.1
Medicare prescription drug coverage (Part B) FSB25.09.6.7
Primary payor chart FSB25.09.6.8
When you are age 65 or over and do not have Medicare FSB25.09.7
Physicians Who Opt-Out of Medicare FSB25.09.8
When you have the Original Medicare Plan (Part A, Part B, or both) FSB25.09.9
Cost-share when Medicare is your primary payor FSB25.09.95
Section 10. Definitions of Terms We Use in This Brochure FSB25.10
Index FSB25.11
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2025 FSB25.12.1
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2025 FSB25.12.2
2025 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan FSB25.13
Cover page FSB25-000-1
Inside cover FSB25-000-2
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