Coverage information - 9
• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the FEHB Program - 9
• Enrollment types available for you and your family - 9
• Family member coverage - 10
• Children’s Equity Act - 10
• Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) - 11
• When benefits and premiums start - 11
• When you retire - 11
When you lose benefits - 11
• When FEHB coverage ends - 11
• Upon divorce - 12
• Temporary Continuation of Coverage (TCC) - 12
• Finding replacement coverage - 12
• Health Insurance Marketplace - 12

Section 1. How This Plan Works - 13

General features of our Standard and Basic Options - 13
We have a Preferred Provider Organization (PPO) - 13
How we pay professional and facility providers - 13
Your rights and responsibilities - 14
Your medical and claims records are confidential - 14

Section 2. Changes for 2027 - 15
Section 3. How You Get Care - 17

Identification cards - 17
Where you get covered care - 17
Balance Billing Protection - 17
• Covered professional providers - 17
• Covered facility providers - 17
What you must do to get covered care - 19
• Transitional care - 20
• If you are hospitalized when your enrollment begins - 20
You need prior Plan approval for certain services - 20
• Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility admission - 21
• Other services - 21
• Surgery by Non-participating providers under Standard Option - 24
How to request precertification for an admission or get prior approval for Other services - 24
• Non-urgent care claims - 24
• Urgent care claims - 25
• Concurrent care claims - 25
• Emergency inpatient admission - 25
• Maternity care - 25
• If your facility stay needs to be extended - 26
• If your treatment needs to be extended - 26
If you disagree with our pre-service claim decision - 26
• To reconsider a non-urgent care claim - 26
• To reconsider an urgent care claim - 26
• To file an appeal with OPM - 26

Section 4. Your Costs for Covered Services - 27

Cost-share/Cost-sharing - 27
Copayment - 27
Deductible - 27
Coinsurance - 28
If your provider routinely waives your cost - 28
Waivers - 28
Differences between our allowance and the bill - 28
Important Notice About Surprise Billing — Know Your Rights - 31
Your costs for other care - 31
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 32
Carryover - 32
If we overpay you - 33
When Government facilities bill us - 33
The Federal Flexible Spending Account Program – FSAFEDS - 33

Section 5. Benefits - 34
Section 5. Standard and Basic Option Overview - 36
Non-FEHB Benefits Available to Plan Members - 134
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 135
Section 7. Filing a Claim for Covered Services - 137
Section 8. The Disputed Claims Process - 141
Section 9. Coordinating Benefits With Medicare and Other Coverage - 144

When you have other health coverage - 144
• TRICARE and CHAMPVA - 144
• Workers’ Compensation - 145
• Medicaid - 145
When other Government agencies are responsible for your care - 145
When others are responsible for injuries - 145
When you have Federal Employees Dental and Vision Insurance Program (FEDVIP) - 147
Clinical trials - 147
When you have Medicare - 147
• The Original Medicare Plan (Part A or Part B) - 147
• Tell us about your Medicare coverage - 148
• Private contract with your physician - 148
• Medicare Advantage (Part C) - 149
• Medicare prescription drug coverage (Part D) - 149
• Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) - 149
When you are age 65 or over and do not have Medicare - 151
Physicians Who Opt-Out of Medicare - 152
When you have the Original Medicare Plan (Part A, Part B, or both) - 152

Section 10. Definitions of Terms We Use in This Brochure - 154
Index - 164
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option – 2027 - 166
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2027 - 168
2027 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan - 174