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Cover Page and Inside Cover

Table of Contents

Introduction/Plain Language/Advisory

5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals

5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals

5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services

5(d). Emergency Services/Accidents

5(e). Mental Health and Substance Use Disorder Benefits

5(f). Prescription Drug Benefits

5(g). Dental Benefits

5(h). Wellness and Other Special Features

5(i). Services, Drugs, and Supplies Provided Overseas

Non-FEHB Benefits Available to Plan Members

Summary of Benefits – Standard Option

Summary of Benefits – Basic Option

2027 Rate Information

FEHB Standard & Basic

Blue Cross and Blue Shield Service Benefit Plan Brochure - 2027

FEHB FEP Blue Standard and FEP Blue Basic Options

Entire brochure in page-number order

Table of Contents

Stop Healthcare Fraud!

Discrimination is Against the Law

Preventing Medical Mistakes

No pre-existing condition limitation

Minimum essential coverage (MEC)

Minimum value standard

Where you can get information about enrolling in the FEHB Program

Enrollment types available for you and your family

Family member coverage

Children's Equity Act

Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP)

When benefits and premiums start

When you retire

When FEHB coverage ends

Temporary Continuation of Coverage (TCC)

Finding replacement coverage

Health Insurance Marketplace

Section 1. How This Plan Works

General features of our Standard and Basic Options//We have a Preferred Provider Organization (PPO)

How we pay professional and facility providers

Your rights and responsibilities

Your medical and claims records are confidential

Section 2. Changes for 2027

Changes to our Standard Option only

Changes to our Basic Option only

Changes to both our Standard and Basic Options

Identification cards

Where you get covered care

Balance Billing Protection

Covered professional providers

Covered facility providers

What you must do to get covered care

Transitional care

If you are hospitalized when your enrollment begins

You need prior Plan Approval for certain services

Inpatient hospital, residential treatment center, or skilled nursing facility admission

Surgery by Non-participating providers under Standard Option

Special prior authorization situations related to coordination of benefits (COB)

How to request precertification for an admission or get approval for Other services

Non-urgent care claims

Urgent care claims

Concurrent care claims

Emergency inpatient admission

If your facility stay needs to be extended

If your treatment needs to be extended

If you disagree with our pre-service claim decision

To reconsider a non-urgent care claim

To reconsider an urgent care claim

To file an appeal with OPM

Cost-share/Cost-sharing

If your provider routinely waives your cost

Differences between our allowance and the bill

Important Notice About Surprise Billing – Know Your Rights

Your costs for other care

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments

If we overpay you

When Government facilities bill us

The Federal Flexible Spending Account Program – FSAFEDS

Section 5. Benefits [Table of Contents]

Section 5. Standard and Basic Option Overview

Section 5(a). Overview

Diagnostic and Treatment Services

Lab, X-ray and Other Diagnostic Tests

Preventive Care, Adult

Preventive Care, Child

Family Planning

Reproductive Services

Treatment Therapies

Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy

Hearing Services (Testing, Treatment, and Supplies)

Vision Services (Testing, Treatment, and Supplies)

Orthopedic and Prosthetic Devices

Durable Medical Equipment (DME)

Medical Supplies

Home Health Services

Manipulative Treatment

Alternative Treatments

Educational Classes and Programs

Section 5(b). Overview

Surgical Procedures

Reconstructive Surgery

Oral and Maxillofacial Surgery

Organ/Tissue Transplants

Section 5(c). Overview

Inpatient Hospital

Outpatient Hospital or Ambulatory Surgical Center

Blue Distinction Specialty Care

Residential Treatment Center - 5(c)

Extended Care Benefits/Skilled Nursing Care Facility Benefits

Section 5(d). Overview

Accidental Injury

Medical Emergency

Section 5(e). Overview

Professional Services

Inpatient Hospital or Other Covered Facility

Residential Treatment Center - 5(e)

Outpatient Hospital or Other Covered Facility

Not Covered (Inpatient or Outpatient)

Section 5(f). Overview

There are important features you should be aware of

Who can write your prescriptions

Where you can obtain them

What is covered

Generic equivalents

Disclosure of information

These are the dispensing limitations

Patient Safety and Quality Monitoring (PSQM)

Standard Option Generic Incentive Program

Here is how to obtain your prescription drugs and supplies

Preferred Retail Pharmacies

Non-preferred Retail Pharmacies

Mail Service Prescription Drug Program

Specialty Drug Pharmacy Program

Asthma Medications

Other Preferred Diabetic Medications, Test Strips, and Supplies

Diabetic Meter Program

Medications to promote better health as recommended under the ACA

Drugs From Other Sources

Section 5(f). MPDP Overview and 5(f)(a). Overview

MPDP There are important features you should be aware of

MPDP Who can write your prescriptions

MPDP Where you can obtain prescription drugs

MPDP What is covered

MPDP Generic equivalents

MPDP Disclosure of information

MPDP These are the dispensing limitations

MPDP Important Contact Information

MPDP Prior Approval

MPDP Medical Foods

MPDP How to obtain your prescription drugs and supplies

MPDP Catastrophic Maximums

MPDP Retail Pharmacies

MPDP Mail Service Prescription Drug Program

MPDP Asthma Medications

MPDP Other Preferred Diabetic Medications, Test Strips, and Supplies

Smoking and Tobacco Cessation Medications

Anti-hypertensive Medications

Over-the-counter (OTC) contraceptive drugs and devices

Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network

Metformin and metformin extended release (excluding osmotic and modified release generic drugs)

Medications to promote better health as recommended under the ACA

Generic medications to reduce breast cancer risk for women

Bowel preparation medications and antiretroviral therapy medications for HIV

Opioid Rescue Agents

Drugs From Other Sources

Section 5(g). Overview

Accidental Injury Benefit

Dental Benefits

Paperless EOBs Incentive

Services for the Deaf and Hearing Impaired

Web Accessibility for the Visually Impaired

Travel Benefit/Services Overseas

Healthy Families

Diabetes Management Program

Blue Health Assessment

Hypertension Management Program

Pregnancy Care Incentive Program

Annual Incentive Limitation

Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B

MyBlue Customer eService

National Doctor & Hospital Finder

Care Management Programs

Flexible Benefits Option

Telehealth Services

The fepblue Mobile Application

Weight Loss Management Program

Section 5(i). Services, Drugs, and Supplies Provided Overseas

Non-FEHB Benefits Available to Plan Members

Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover

Section 7. Filing a Claim for Covered Services

Section 8. The Disputed Claims Process

When you have other health coverage

TRICARE and CHAMPVA

Workers' Compensation

When other Government agencies are responsible for your care

When others are responsible for injuries

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP)

Clinical trials

When you have Medicare

The Original Medicare Plan (Part A or Part B)

Tell us about your Medicare coverage

Private contract with your physician

Medicare Advantage (Part C)

Medicare prescription drug coverage (Part D)

Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP)

Medicare prescription drug coverage (Part B)

Primary payor chart

When you are age 65 or over and do not have Medicare

Physicians Who Opt-Out of Medicare

When you have the Original Medicare Plan (Part A, Part B, or both)

Cost-share when Medicare is your primary payor

Section 10. Definitions of Terms We Use in This Brochure

Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2027

Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2027

2027 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan

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