Blue Cross Blue Shield Federal Employee Program logo
 
 

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
1 FSB25-001
2 FSB25-002
3 FSB25-003
4 FSB25-004
5 FSB25-005
6 FSB25-006
7 FSB25-007
8 FSB25-008
9 FSB25-009
10 FSB25-010
11 FSB25-011
12 FSB25-012
13 FSB25-013
14 FSB25-014
15 FSB25-015
16 FSB25-016
17 FSB25-017
18 FSB25-018
19 FSB25-019
20 FSB25-020
21 FSB25-021
22 FSB25-022
23 FSB25-023
24 FSB25-024
25 FSB25-025
26 FSB25-026
27 FSB25-027
28 FSB25-028
29 FSB25-029
30 FSB25-030
31 FSB25-031
32 FSB25-032
33 FSB25-033
34 FSB25-034
35 FSB25-035
36 FSB25-036
37 FSB25-037
38 FSB25-038
39 FSB25-039
40 FSB25-040
41 FSB25-041
42 FSB25-042
43 FSB25-043
44 FSB25-044
45 FSB25-045
46 FSB25-046
47 FSB25-047
48 FSB25-048
49 FSB25-049
50 FSB25-050
51 FSB25-051
52 FSB25-052
53 FSB25-053
54 FSB25-054
55 FSB25-055
56 FSB25-056
57 FSB25-057
58 FSB25-058
59 FSB25-059
60 FSB25-060
61 FSB25-061
62 FSB25-062
63 FSB25-063
64 FSB25-064
65 FSB25-065
66 FSB25-066
67 FSB25-067
68 FSB25-068
69 FSB25-069
70 FSB25-070
71 FSB25-071
72 FSB25-072
73 FSB25-073
74 FSB25-074
75 FSB25-075
76 FSB25-076
77 FSB25-077
78 FSB25-078
79 FSB25-079
80 FSB25-080
81 FSB25-081
82 FSB25-082
83 FSB25-083
Document Name Document Number
84 FSB25-084
85 FSB25-085
86 FSB25-086
87 FSB25-087
88 FSB25-088
89 FSB25-089
90 FSB25-090
91 FSB25-091
92 FSB25-092
93 FSB25-093
94 FSB25-094
95 FSB25-095
96 FSB25-096
97 FSB25-097
98 FSB25-098
99 FSB25-099
100 FSB25-100
101 FSB25-101
102 FSB25-102
103 FSB25-103
104 FSB25-104
105 FSB25-105
106 FSB25-106
107 FSB25-107
108 FSB25-108
109 FSB25-109
110 FSB25-110
111 FSB25-111
112 FSB25-112
113 FSB25-113
114 FSB25-114
115 FSB25-115
116 FSB25-116
117 FSB25-117
118 FSB25-118
119 FSB25-119
120 FSB25-120
121 FSB25-121
122 FSB25-122
123 FSB25-123
124 FSB25-124
125 FSB25-125
126 FSB25-126
127 FSB25-127
128 FSB25-128
129 FSB25-129
130 FSB25-130
131 FSB25-131
132 FSB25-132
133 FSB25-133
134 FSB25-134
135 FSB25-135
136 FSB25-136
137 FSB25-137
138 FSB25-138
139 FSB25-139
140 FSB25-140
141 FSB25-141
142 FSB25-142
143 FSB25-143
144 FSB25-144
145 FSB25-145
146 FSB25-146
147 FSB25-147
148 FSB25-148
149 FSB25-149
150 FSB25-150
151 FSB25-151
152 FSB25-152
153 FSB25-153
154 FSB25-154
155 FSB25-155
156 FSB25-156
157 FSB25-157
158 FSB25-158
159 FSB25-159
160 FSB25-160
161 FSB25-161
162 FSB25-162
163 FSB25-163
164 FSB25-164
165 FSB25-165
166 FSB25-166
167 FSB25-167
168 FSB25-168
169 FSB25-169
170 FSB25-170
 

© 2024 Blue Cross Blue Shield Association. All rights reserved.

Back to Top