Blue Cross
®
and Blue Shield
®
Service Benefit Plan
www.fepblue.org
2024
A Fee-For-Service Plan (FEP Blue Standard and FEP Blue Basic Options) with
a Preferred Provider Organization
Correction to 2024 brochure
Please note the following correction to the brochure:
• Page 165, Mental health and substance use disorder treatment – The Basic Option office visit copayment is $35, not
$30.
Blue Cross
®
and Blue Shield
®
Service Benefit Plan
www.fepblue.org
2024
A Fee-For-Service Plan (FEP Blue Standard and FEP Blue Basic Options) with
a Preferred Provider Organization
IMPORTANT
•Rates: Back Cover
•Changes for 2024: Page 14
•Summary of Benefits: Page 163
This Plan’s health coverage qualifies as minimum essential coverage
and meets the minimum value standard for the benefits it provides. See
our FEHB Facts for details. This Plan is accredited. See Section 1.
Sponsored and administered by: The Blue Cross and Blue Shield
Association and participating Blue Cross and Blue Shield Plans
Who may enroll in this Plan: All Federal employees, Tribal
employees, and annuitants who are eligible to enroll in the Federal
Employees Health Benefits Program
Enrollment codes for this Plan:
104 Standard Option - Self Only
106 Standard Option - Self Plus One
105 Standard Option - Self and Family
111 Basic Option - Self Only
113 Basic Option - Self Plus One
112 Basic Option - Self and Family
RI 71-005
Important Notice from the Blue Cross and Blue Shield Service Benefit Plan About
Our Prescription Drug Coverage and Medicare
The Office of Personnel Management (OPM) has determined that the Blue Cross and Blue Shield Service Benefit Plan’s prescription
drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan
participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for
prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as
long as you keep your FEHB coverage.
However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits
with Medicare.
Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.
Please be advised
If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as
Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every
month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage,
your premium will always be at least 19% higher than what many other people pay. You will have to pay this higher premium as long
as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election
Period (October 15 through December 7) to enroll in Medicare Part D.
Medicare’s Low Income Benefits
For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information
regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the
SSA at 800-772-1213, TTY: 711.
You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:
•Visit www.medicare.gov for personalized help.
•Call 800-MEDICARE 800-633-4227, TTY 711.
Potential Additional Premium for Medicare's High Income Members
Income-Related Monthly Adjustment Amount (IRMAA)
The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an amount you may pay in addition to your FEHB premium
to enroll in and maintain Medicare prescription drug coverage. This additional premium is assessed only to those with higher
incomes and is adjusted based on the income reported on your IRS tax return. You do not make any IRMAA payment to your
FEHB plan. Refer to the Part D-IRMAA section of the Medicare website to see if you would be subject to this additional premium.
RI 71-005
Table of Contents
Introduction ...................................................................................................................................................................................4
Plain Language ..............................................................................................................................................................................4
Stop Healthcare Fraud! .................................................................................................................................................................4
Discrimination is Against the Law ................................................................................................................................................5
Preventing Medical Mistakes ........................................................................................................................................................6
FEHB Facts ...................................................................................................................................................................................8
Coverage information .........................................................................................................................................................8
• No pre-existing condition limitation ...............................................................................................................................8
• Minimum essential coverage (MEC) ..............................................................................................................................8
• Minimum value standard ................................................................................................................................................8
• Where you can get information about enrolling in the FEHB Program .........................................................................8
• Enrollment types available for you and your family ......................................................................................................8
• Family member coverage ...............................................................................................................................................9
• Children’s Equity Act .....................................................................................................................................................9
• When benefits and premiums start ...............................................................................................................................10
• When you retire ............................................................................................................................................................10
When you lose benefits .....................................................................................................................................................10
• When FEHB coverage ends ..........................................................................................................................................10
• Upon divorce .................................................................................................................................................................11
• Temporary Continuation of Coverage (TCC) ...............................................................................................................11
• Finding replacement coverage ......................................................................................................................................11
• Health Insurance Marketplace ......................................................................................................................................11
Section 1. How This Plan Works ................................................................................................................................................12
General features of our Standard and Basic Options ........................................................................................................12
We have a Preferred Provider Organization (PPO) ...........................................................................................................12
How we pay professional and facility providers ...............................................................................................................12
Your rights and responsibilities .........................................................................................................................................13
Your medical and claims records are confidential ............................................................................................................13
Section 2. Changes for 2024 .......................................................................................................................................................14
Changes to our Standard Option only ...............................................................................................................................14
Changes to our Basic Option only ....................................................................................................................................14
Changes to both our Standard and Basic Options .............................................................................................................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 ............................................................................................................................................18
What you must do to get covered care ..............................................................................................................................20
• Transitional care ...........................................................................................................................................................20
• If you are hospitalized when your enrollment begins ...................................................................................................20
You need prior Plan approval for certain services ............................................................................................................21
•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 .................................................................................................................................................25
• Urgent care claims ........................................................................................................................................................25
1 2024 Blue Cross® and Blue Shield® Service Benefit Plan Table of Contents
• Concurrent care claims .................................................................................................................................................25
• Emergency inpatient admission ....................................................................................................................................26
• Maternity care ...............................................................................................................................................................26
• 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 ..........................................................................................................................27
• To reconsider an urgent care claim ...............................................................................................................................27
• To file an appeal with OPM ..........................................................................................................................................27
Section 4. Your Costs for Covered Services ...............................................................................................................................28
Cost-share/Cost-sharing ....................................................................................................................................................28
Copayment ........................................................................................................................................................................28
Deductible .........................................................................................................................................................................28
Coinsurance .......................................................................................................................................................................29
If your provider routinely waives your cost ......................................................................................................................29
Waivers ..............................................................................................................................................................................29
Differences between our allowance and the bill ...............................................................................................................29
Important Notice About Surprise Billing — Know Your Rights ......................................................................................32
Your costs for other care ...................................................................................................................................................32
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments ...........................33
Carryover ..........................................................................................................................................................................33
If we overpay you .............................................................................................................................................................34
When Government facilities bill us ..................................................................................................................................34
The Federal Flexible Spending Account Program – FSAFEDS .......................................................................................34
Section 5. Benefits ......................................................................................................................................................................35
Section 5. Standard and Basic Option Overview ..............................................................................................................37
Non-FEHB Benefits Available to Plan Members ...........................................................................................................133
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover .................................................................134
Section 7. Filing a Claim for Covered Services ........................................................................................................................136
Section 8. The Disputed Claims Process ...................................................................................................................................139
Section 9. Coordinating Benefits With Medicare and Other Coverage ....................................................................................142
When you have other health coverage ............................................................................................................................142
• TRICARE and CHAMPVA ........................................................................................................................................142
• Workers’ Compensation ..............................................................................................................................................143
• Medicaid .....................................................................................................................................................................143
When other Government agencies are responsible for your care ...................................................................................143
When others are responsible for injuries .........................................................................................................................143
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) ........................................................145
Clinical trials ...................................................................................................................................................................145
When you have Medicare ...............................................................................................................................................145
• The Original Medicare Plan (Part A or Part B) ...........................................................................................................145
• Tell us about your Medicare coverage ........................................................................................................................146
• Private contract with your physician ..........................................................................................................................146
• Medicare Advantage (Part C) .....................................................................................................................................147
• Medicare prescription drug coverage (Part D) ...........................................................................................................147
• Medicare prescription drug coverage (Part B) ...........................................................................................................147
When you are age 65 or over and do not have Medicare ................................................................................................149
Physicians Who Opt-Out of Medicare ............................................................................................................................150
When you have the Original Medicare Plan (Part A, Part B, or both) ............................................................................150
Section 10. Definitions of Terms We Use in This Brochure .....................................................................................................152
Index ..........................................................................................................................................................................................161
2 2024 Blue Cross® and Blue Shield® Service Benefit Plan Table of Contents
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option – 2024 ..............................163
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2024 ....................................165
2024 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan ....................................................................170
3 2024 Blue Cross® and Blue Shield® Service Benefit Plan Table of Contents
Introduction
This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Standard and FEP Blue
Basic Options under contract (CS 1039) between the Blue Cross and Blue Shield Association and the United States Office of
Personnel Management, as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by participating Blue
Cross and Blue Shield Plans (Local Plans) that administer this Plan in their individual localities. For customer service assistance, visit
our website, www.fepblue.org, or contact your Local Plan at the phone number appearing on the back of your ID card.
The address for the Blue Cross and Blue Shield Service Benefit Plan administrative office is:
Blue Cross and Blue Shield Service Benefit Plan
750 9th Street NW
Washington, DC 20001-4524
This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your healthcare benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2024, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates for each plan annually. Benefit changes are effective January 1, 2024, and changes are summarized
in Section 2. Rates are shown on the back cover of this brochure.
Plain Language
All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:
•Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family
member; “we” means the Blue Cross and Blue Shield Service Benefit Plan.
•We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office
of Personnel Management. If we use others, we tell you what they mean.
•Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.
Stop Healthcare Fraud!
Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.
OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the
agency that employs you or from which you retired.
Protect Yourself From Fraud – Here are some things you can do to prevent fraud:
•Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare provider,
authorized health benefits plan, or OPM representative.
•Let only the appropriate medical professionals review your medical record or recommend services.
•Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
•Carefully review explanations of benefits (EOBs) statements that you receive from us.
•Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
•Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
4 2024 Blue Cross® and Blue Shield® Service Benefit Plan Introduction/Plain Language/Advisory
•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:
- Call the provider and ask for an explanation. There may be an error.
- If the provider does not resolve the matter, call the FEP Fraud Hotline at 800-FEP-8440 (800-337-8440) and explain the
situation.
- If we do not resolve the issue:
CALL THE HEALTHCARE FRAUD HOTLINE
877-499-7295
OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form
The online form is the desired method of reporting fraud in order to ensure accuracy, and a quick response time.
You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100
•Do not maintain as a family member on your policy:
- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
- Your child age 26 or over (unless they were disabled and incapable of self-support prior to age 26)
•A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s
FEHB enrollment.
•If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your
retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary
Continuation of Coverage (TCC).
•Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your
agency may take action against you. Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining
service or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when you are no longer
eligible.
•If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and
premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be
billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for
which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your
health insurance coverage.
Discrimination is Against the Law
The health benefits described in this brochure are consistent with applicable laws prohibiting discrimination.
We:
•Provide free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
•Provide free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Civil Rights Coordinator of your Local Plan by contacting your Local Plan at the phone number
appearing on the back of your ID card.
5 2024 Blue Cross® and Blue Shield® Service Benefit Plan Introduction/Plain Language/Advisory
If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin,
age, disability, or sex, you can file a grievance with the Civil Rights Coordinator of your Local Plan. You can file a grievance in
person or by mail, fax, or email. If you need help filing a grievance, your Local Plan’s Civil Rights Coordinator is available to help
you.
Members may file a complaint with the HHS Office for Civil Rights, OPM, or FEHB Program Carriers.
For further information about how to file a civil rights complaint, go to www.fepblue.org/en/rights-and-responsibilities/, or call the
customer service phone number on the back of your member ID card. For TTY, dial 711.
Preventing Medical Mistakes
Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic
outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and
additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and
healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies.
You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and
understanding your risks. Take these simple steps:
1. Ask questions if you have doubts or concerns.
•Ask questions and make sure you understand the answers.
•Choose a doctor with whom you feel comfortable talking.
•Take a relative or friend with you to help you take notes, ask questions, and understand answers.
2. Keep and bring a list of all the medications you take.
•Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosages that you take, including
non-prescription (over-the-counter) medications and nutritional supplements.
•Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as latex.
•Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor
or pharmacist says.
•Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you
expected.
•Read the label and patient package insert when you get your medication, including all warnings and instructions.
•Know how to use your medication. Especially note the times and conditions when your medication should and should not be
taken.
•Contact your doctor or pharmacist if you have any questions.
•Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from
taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.
3. Get the results of any test or procedure.
•Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or
Provider's portal?
•Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your
results.
•Ask what the results mean for your care.
4. Talk to your doctor about which hospital or clinic is best for your health needs.
•Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital
or clinic to choose from to get the healthcare you need.
•Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.
6 2024 Blue Cross® and Blue Shield® Service Benefit Plan Introduction/Plain Language/Advisory
5. Make sure you understand what will happen if you need surgery.
•Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
•Ask your doctor, “Who will manage my care when I am in the hospital?”
•Ask your surgeon:
- “Exactly what will you be doing?”
- “About how long will it take?”
- “What will happen after surgery?”
- “How can I expect to feel during recovery?”
•Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional
supplements you are taking.
Patient Safety Links
For more information on patient safety, please visit:
• www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps healthcare organizations to improve the quality
and safety of the care they deliver.
• www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics
not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care
you receive.
• www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about
the safe, appropriate use of medications.
• www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
• www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve
patient safety.
Preventable Healthcare Acquired Conditions (“Never Events”)
When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or
other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable,
patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions.
Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients can indicate a significant
problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called “Never Events” or
“Serious Reportable Events.”
We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain
infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither
you nor your FEHB Plan will incur costs to correct the medical error.
You will not be billed for inpatient services when care is related to treatment of specific hospital-acquired conditions if you use
Preferred or Member hospitals. This policy helps to protect you from having to pay for the cost of treating these conditions, and it
encourages hospitals to improve the quality of care they provide.
7 2024 Blue Cross® and Blue Shield® Service Benefit Plan Introduction/Plain Language/Advisory
FEHB Facts
Coverage information
We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan
solely because you had the condition before you enrolled.
• No pre-existing
condition limitation
Coverage under this Plan qualifies as minimum essential coverage. Please visit the Internal Revenue
Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-
Responsibility-Provision for more information on the individual requirement for MEC.
• Minimum essential
coverage (MEC)
Our health coverage meets the minimum value standard of 60% established by the ACA. This means
that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits.
The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained
in this brochure.
• Minimum value
standard
See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:
• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems
Also, your employing or retirement office can answer your questions, give you other plans' brochures
and other materials you need to make an informed decision about your FEHB coverage. These
materials tell you:
• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter
military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins
We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment
status without information from your employing or retirement office. For information on your
premium deductions, you must also contact your employing or retirement office.
Once enrolled in your FEHB Program Plan, you should contact your carrier directly for
updates and questions about your benefit coverage.
• Where you can get
information about
enrolling in the
FEHB Program
Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one
eligible family member. Self and Family coverage is for the enrollee and one or more eligible family
members. Family members include your spouse and your dependent children under age 26, including
any foster children authorized for coverage by your employing agency or retirement office. Under
certain circumstances, you may also continue coverage for a disabled child 26 years of age or older
who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family
enrollment if you marry, give birth, or add a child to your family. You may change your enrollment
31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins
on the first day of the pay period in which the child is born or becomes an eligible family member.
When you change to Self Plus One or Self and Family because you marry, the change is effective on
the first day of the pay period that begins after your employing office receives your enrollment form.
Benefits will not be available until you are married. A carrier may request that an enrollee verify the
eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.
• Enrollment types
available for you
and your family
8 2024 Blue Cross® and Blue Shield® Service Benefit Plan FEHB Facts
Contact your employing or retirement office if you want to change from Self Only to Self Plus One
or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family
member.
Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits. Please tell us immediately of changes in family member status, including
your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to
you 60 days before we proactively disenroll your child on midnight of their 26th birthday, unless
your child is eligible for continued coverage because they are incapable of support due to a physical
or mental disability that began before age 26.
If you or one of your family members is enrolled in one FEHB plan, you or they cannot be
enrolled in or covered as a family member by another enrollee in another FEHB plan.
If you have a qualifying life event (QLE) – such as marriage, divorce, or the birth of a child – outside
of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change
your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.
opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing
agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.
Family members covered under your Self and Family enrollment are your spouse (including your
spouse by valid common-law marriage if you reside in a state that recognizes common-law
marriages) and children as described below. A Self Plus One enrollment covers you and your spouse,
or one other eligible family member as described below.
Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.
Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide
documentation of your regular and substantial support of the child and sign a certification stating that
your foster child meets all the requirements. Contact your human resources office or retirement
system for additional information.
Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that
began before age 26 are eligible to continue coverage. Contact your human resources office or
retirement system for additional information.
Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th
birthday.
Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are
covered until their 26th birthday.
Newborns of covered children are insured only for routine nursery care during the covered portion of
the mother's maternity stay.
You can find additional information at www.opm.gov/healthcare-insurance.
• Family member
coverage
OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law
mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program,
if you are an employee subject to a court or administrative order requiring you to provide health
benefits for your child or children.
If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health
plan that provides full benefits in the area where your children live or provide documentation to your
employing office that you have obtained other health benefits coverage for your children. If you do
not do so, your employing office will enroll you involuntarily as follows:
• Children’s Equity
Act
9 2024 Blue Cross® and Blue Shield® Service Benefit Plan FEHB Facts
• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self
and Family coverage, as appropriate, in the lowest-cost nationwide Plan option as determined by
OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area
where your children live, your employing office will change your enrollment to Self Plus One or
Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your
employing office will change your enrollment to Self Plus One or Self and Family, as
appropriate, in the lowest-cost nationwide plan option as determined by OPM.
As long as the court/administrative order is in effect, and you have at least one child identified in the
order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to
Self Only, or change to a plan that does not serve the area in which your children live, unless you
provide documentation that you have other coverage for the children.
If the court/administrative order is still in effect when you retire, and you have at least one child still
eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and
cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in
which your children live as long as the court/administrative order is in effect. Similarly, you cannot
change to Self Plus One if the court/administrative order identifies more than one child. Contact your
employing office for further information.
The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season,
your coverage begins on the first day of your first pay period that starts on or after January 1. If you
changed plans or Plan options during Open Season and you receive care between January 1
and the effective date of coverage under your new plan or option, your claims will be processed
according to the 2024 benefits of your prior plan or option. If you have met (or pay cost-sharing
that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not
pay cost-sharing for services covered between January 1 and the effective date of coverage under
your new plan or option. However, if your prior plan left the FEHB Program at the end of the year,
you are covered under that plan’s 2023 benefits until the effective date of your coverage with your
new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time
during the year, your employing office will tell you the effective date of coverage.
If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated
from Federal service), and premiums are not paid, you will be responsible for all benefits paid during
the period in which premiums were not paid. You may be billed for services received directly from
your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for
which you have not paid premiums. It is your responsibility to know when you or family members
are no longer eligible to use your health insurance coverage.
• When benefits and
premiums start
When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled
in the FEHB Program for the last five years of your Federal service. If you do not meet this
requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of
Coverage (TCC).
• When you retire
When you lose benefits
You will receive an additional 31 days of coverage, for no additional premium, when:
• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.
Any person covered under the 31-day extension of coverage who is confined in a hospital or other
institution for care or treatment on the 31st day of the temporary extension is entitled to continuation
of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day
after the end of the 31-day temporary extension.
• When FEHB
coverage ends
10 2024 Blue Cross® and Blue Shield® Service Benefit Plan FEHB Facts
You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy
(non-FEHB individual policy). FEP helps members with Temporary Continuation of Coverage
(TCC) and with finding replacement coverage.
If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered
as a family member under your Self Plus One or Self and Family enrollment. You must contact us to
let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask
for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your
employing or retirement office. A change will not automatically be made.
If you were married to an enrollee and your divorce or annulment is final, you may not remain
covered as a family member under your former spouse’s enrollment. This is the case even when the
court has ordered your former spouse to provide health benefits coverage for you. However, you may
be eligible for your own FEHB coverage under either the spouse equity law or TCC. If you are
recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement
office to get additional information about your coverage choices. You can also visit OPM’s website,
www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. We may request that you
verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB
enrollment.
• Upon divorce
If you leave Federal service or Tribal employment, or if you lose coverage because you no longer
qualify as a family member, you may be eligible for TCC. For example, you can receive TCC if you
are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, or if you
are a covered child and you turn age 26, regardless of marital status, etc.
You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement
office or from www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. It explains
what you have to do to enroll.
Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on
your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.
HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs
would be before you make a decision to enroll. Finally, if you qualify for coverage under another
group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you
apply within 30 days of losing FEHB coverage.
We also want to inform you that the Patient Protection and ACA did not eliminate TCC or change the
TCC rules.
• Temporary
Continuation of
Coverage (TCC)
If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace,
please refer to the next Section of this brochure. We will help you find replacement coverage inside
or outside the Marketplace. For assistance, please contact your Local Plan at the phone number
appearing on the back of your ID card, or visit www.bcbs.com to access the website of your Local
Plan.
Note: We do not determine who is eligible to purchase health benefits coverage inside the ACA’s
Health Insurance Marketplace. These rules are established by the Federal Government agencies that
have responsibility for implementing the ACA and by the Marketplace.
• Finding replacement
coverage
If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace,
please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and
Human Services that provides up-to-date information on the Marketplace.
• Health Insurance
Marketplace
11 2024 Blue Cross® and Blue Shield® Service Benefit Plan FEHB Facts
Section 1. How This Plan Works
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other healthcare providers. We
reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent
of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.
OPM requires that FEHB plans be accredited to validate that Plan operations and/or care management meet nationally recognized
standards. The local Plans and vendors that support the Blue Cross and Blue Shield Service Benefit Plan hold accreditation from
National Committee for Quality Assurance (NCQA) and/or URAC. To learn more about this Plan’s accreditations, please visit the
following websites:
•National Committee for Quality Assurance ( www.ncqa.org);
•URAC ( www.URAC.org).
General features of our Standard and Basic Options
We have a Preferred Provider Organization (PPO)
Our fee-for-service Plan offers services through a PPO. This means that certain hospitals and other healthcare providers are “Preferred
providers.” When you use our PPO (Preferred) providers, you will receive covered services at a reduced cost. Your Local Plan (or, for
Preferred retail pharmacies, CVS Caremark) is solely responsible for the selection of PPO providers in your area. Contact your Local
Plan for the names of PPO (Preferred) providers and to verify their continued participation. You can also visit www.fepblue.org/
provider/ to use our National Doctor & Hospital Finder. You can reach our website through the FEHB website, www.opm.gov/
healthcare-insurance.
Under Standard Option, PPO (Preferred) benefits apply only when you use a PPO (Preferred) provider. PPO networks may be more
extensive in some areas than in others. We cannot guarantee the availability of every specialty in all areas. If no PPO (Preferred)
provider is available, or you do not use a PPO (Preferred) provider, non-PPO (non-preferred) benefits apply.
Under Basic Option, you must use Preferred providers in order to receive benefits. See Section 3 for the exceptions to this
requirement.
Note: Dentists and oral surgeons who are in our Preferred Dental Network for routine dental care are not necessarily Preferred
providers for other services covered by this Plan under other benefit provisions (such as the surgical benefit for oral and maxillofacial
surgery). Call us at the customer service phone number on the back of your ID card to verify that your provider is Preferred for the
type of care (e.g., routine dental care or oral surgery) you are scheduled to receive.
How we pay professional and facility providers
We pay benefits when we receive a claim for covered services. Each Local Plan contracts with hospitals and other healthcare
facilities, physicians, and other healthcare professionals in its service area, and is responsible for processing and paying claims for
services you receive within that area. Many, but not all, of these contracted providers are in our PPO (Preferred) network.
•PPO providers. PPO (Preferred) providers have agreed to accept a specific negotiated amount as payment in full for covered
services provided to you. We refer to PPO facility and professional providers as “Preferred.” They will generally bill the Local
Plan directly, who will then pay them directly. You do not file a claim. Your out-of-pocket costs are generally less when you receive
covered services from Preferred providers, and are limited to your coinsurance or copayments (and, under Standard Option only,
the applicable deductible).
•Participating providers. Some Local Plans also contract with other providers that are not in our Preferred network. If they are
professionals, we refer to them as “Participating” providers. If they are facilities, we refer to them as “Member” facilities.
They have agreed to accept a different negotiated amount than our Preferred providers as payment in full. They will also generally
file your claims for you. They have agreed not to bill you for more than your applicable deductible, and coinsurance or copayments,
for covered services. We pay them directly, but at our Non-preferred benefit levels. Your out-of-pocket costs will be greater than if
you use Preferred providers.
Note: Not all areas have Participating providers and/or Member facilities. To verify the status of a provider, please contact the Local
Plan where the services will be performed.
12 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 1
•Non-participating providers. Providers who are not Preferred or Participating providers do not have contracts with us, and may or
may not accept our allowance. We refer to them as “Non-participating providers” generally, although if they are facilities we
refer to them as “Non-member facilities.” When you use Non-participating providers, you may have to file your claims with us.
We will then pay our benefits to you, and you must pay the provider.
You must pay any difference between the amount Non-participating providers charge and our allowance (except in certain
circumstances – see NSA in Section 4). In addition, you must pay any applicable coinsurance amounts, copayment amounts,
amounts applied to your calendar year deductible, and amounts for noncovered services. Important: Under Standard Option,
your out-of-pocket costs may be substantially higher when you use Non-participating providers than when you use
Preferred or Participating providers. Under Basic Option, you must use Preferred providers to receive benefits. See Section 3 for
the exceptions to this requirement.
Note: In Local Plan areas, Preferred providers and Participating providers who contract with us will accept 100% of the Plan
allowance as payment in full for covered services. As a result, you are only responsible for applicable coinsurance or copayments
(and, under Standard Option only, the applicable deductible), for covered services, and any charges for noncovered services.
•Pilot Programs. We may implement pilot programs in one or more Local Plan areas and overseas to test the feasibility and
examine the impact of various initiatives. The pilot programs do not affect all Plan areas. Information on specific pilots is not
published in this brochure; it is communicated to members and network providers in accordance with our agreement with OPM.
Certain pilot programs may incorporate benefits that are different from those described in this brochure. For example, certain pilot
programs may revise the Plan Allowance for Non-participating providers described in Section 10 of this brochure.
Your rights and responsibilities
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our
networks, and our providers. OPM’s FEHB website ( www.opm.gov/insure) lists the specific types of information that we must make
available to you. Some of the required information is listed below.
•Years in existence
•Profit status
•Care management, including case management and disease management programs
•How we determine if procedures are experimental or investigational
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can
view the complete list of these rights and responsibilities by visiting our website, at www.fepblue.org/en/rights-and-responsibilities.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our
website at www.fepblue.org/en/terms-and-privacy/notice-of-privacy-practices/ to obtain our Notice of Privacy Practices. You can also
contact us to request that we mail you a copy of that Notice.
If you want more information about us, call or write to us. Our phone number is shown on the back of your Service Benefit Plan ID
card. You may also visit our website at www.fepblue.org.
Your medical and claims records are confidential
We will keep your medical and claims information confidential.
Note: As part of our administration of this contract, we may disclose your medical and claims information (including your prescription
drug utilization) to any treating physicians or dispensing pharmacies. You may view our Notice of Privacy Practice for more
information about how we may use and disclose member information by visiting our website at www.fepblue.org.
13 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 1
Section 2. Changes for 2024
Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 (Benefits).
Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not
change benefits.
Changes to our Standard Option only
•We no longer require a signed consent form agreeing to enrollment into and active participation in case management during a
skilled nursing facility (SNF) stay prior to admission for members who do not have primary Medicare Part A. Previously, this was
required prior to admission into a SNF.
•We now provide coverage for assisted reproductive technology (ART) procedures and services, limited to $25,000 annually for
members who meet our definition of infertility and obtain prior approval. Previously, we did not provide coverage for these
services. (See page 49.)
•Your copayment for office visits, physical therapy, occupational therapy, speech therapy, cognitive rehabilitation therapy, vision
services, foot care services, and manipulative treatments when performed by Preferred primary care providers or other healthcare
professionals, and when applicable Preferred facilities, is now $30 per visit. Previously, your copayment for these services was $25
per visit. (See pages 28, 37, 39, 52, 54, 58, 79, 94, 151, 163 and 164.)
•Your copayment for office visits, physical therapy, occupational therapy, speech therapy, cognitive rehabilitation therapy, vision
services, and foot care services when performed by a Preferred specialist is now $40 per visit. Previously, your copayment for these
services was $35 per visit. (See pages 37, 39, 52, 54, 151, and 163.)
•For eligible members, prescription drug benefits will now be provided under a new FEP Medicare Prescription Drug Program.
Previously, we did not offer a separate prescription drug program. (See page 108.)
•Members enrolled under the FEP Medicare Prescription Drug Program will have a separate pharmacy drug out-of-pocket
catastrophic maximum of $2,000. Previously, there was no separate catastrophic maximum. (See page 111.)
•For members enrolled in the FEP Medicare Prescription Drug Program, your copayment for Tier 1 generic drugs purchased at a
network pharmacy is $5 for each purchase of up to a 30-day supply and $15 for a 31 to 90-day supply, deductible does not apply.
Tier 1 generic drugs purchased through the Mail Service Prescription Drug Program are subject to a $5 copayment. Previously, we
did not provide this separate prescription drug program. (See pages 111-112.)
•For members enrolled in the FEP Medicare Prescription Drug Program, your coinsurance for Tier 2 preferred brand-name drugs
purchased at a network pharmacy is 15% of the Plan allowance for each purchase of up to a 90-day supply, deductible does not
apply. Tier 2 preferred brand-name drugs purchased through the Mail Service Prescription Drug Program are subject to an $85
copayment. Previously, we did not provide this separate prescription drug program. (See pages 111-112.)
•For members enrolled in the FEP Medicare Prescription Drug Program, your coinsurance for Tier 3 non-preferred brand-name
drugs purchased at a network pharmacy is 50% of the Plan allowance for each purchase of up to a 90-day supply, deductible does
not apply. Tier 3 non-preferred brand-name drugs purchased through the Mail Service Prescription Drug Program are subject to a
$125 copayment. Previously, we did not provide this separate prescription drug program. (See pages 111-112.)
•For members enrolled in the FEP Medicare Prescription Drug Program, your copayment for Tier 4 specialty drugs purchased at a
network pharmacy is $60 for each purchase of up to a 30-day supply; $170 for a 31 to 90-day supply, deductible does not apply.
Tier 4 specialty drugs purchased through the Mail Service Prescription Drug Program are subject to a $150 copayment. Previously,
we did not provide this separate prescription drug program. (See pages 111-112.)
Changes to our Basic Option only
•Your copayment for office visits, allergy care, treatment therapies and services, physical therapy, occupational therapy, speech
therapy, cognitive rehabilitation therapy, hearing services, vision services, foot care services, skilled home nursing care,
manipulative and alternative treatments, diabetic education, and dental services when performed by Preferred primary care
providers or other healthcare professionals, and when applicable Preferred facilities is now $35 per visit. Previously, your
copayment for these services was $30 per visit. (See pages 29, 32, 37, 39, 50, 51, 52, 53, 54, 58, 59, 60, 79, 80, 94, 96, 121, 124,
151, 165 and 166.)
14 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 2
•Your copayment for office visits, allergy care, treatment therapies and services, physical therapy, occupational therapy, speech
therapy, cognitive rehabilitation therapy, hearing services, vision services, foot care services, alternative treatments, and diabetic
education, when performed by Preferred specialists is now $45 per visit. Previously, your copayment for these services was $40 per
visit. (See pages 37, 39, 50, 51, 52, 53, 54, 58, 59, 60, 151, and 165.)
•For eligible members, prescription drug benefits will now be provided under a new FEP Medicare Prescription Drug Program.
Previously, we did not offer a separate prescription drug program. (See page 108.)
•Members enrolled in the FEP Medicare Prescription Drug Program will have a separate pharmacy drug out-of-pocket catastrophic
maximum of $3,250. Previously, there was no separate catastrophic maximum. (See page 111.)
•For members enrolled in the FEP Medicare Prescription Drug Program, your copayment for Tier 1 generic drugs purchased at a
network pharmacy is $10 for each purchase of up to a 30-day supply and $30 for a 31 to 90-day supply. Tier 1 generic drugs
purchased through the Mail Service Prescription Drug Program are subject to a $15 copayment. Previously, we did not provide this
separate prescription drug program. (See pages 111-112.)
•For members enrolled in the FEP Medicare Prescription Drug Program, your copayment for Tier 2 preferred brand-name drugs
purchased at a network pharmacy is $45 for each purchase of up to a 30-day supply and $135 for a 31 to 90-day supply. Tier 2
preferred brand-name drugs purchased through the Mail Service Prescription Drug Program are subject to a $95 copayment.
Previously, we did not provide this separate prescription drug program. (See pages 111-112.)
•For members enrolled in the FEP Medicare Prescription Drug Program, your coinsurance for Tier 3 non-preferred brand-name
drugs purchased at a network pharmacy is 50% of the Plan allowance ($60 minimum) for each purchase of up to a 30-day supply,
and 50% of the Plan allowance ($175 minimum) for a 31 to 90-day supply. Tier 3 non-preferred brand-name drugs purchased
through the Mail Service Prescription Drug Program are subject to a $125 copayment. Previously, we did not provide this separate
prescription drug program. (See pages 111-112.)
•For members enrolled in the FEP Medicare Prescription Drug Program, your copayment for Tier 4 specialty drugs purchased at a
network pharmacy is $75 for each purchase of up to a 30-day supply and $195 for a 31 to 90-day supply. Tier 4 specialty drugs
purchased through the Mail Service Prescription Drug Program are subject to a $150 copayment. Previously, we did not provide
this separate prescription drug program. (See pages 111-112.)
Changes to both our Standard and Basic Options
•We no longer require written consent and participation in a case management program prior to admission for inpatient care
provided by a residential treatment center (RTC). Previously, this was required prior to admission into an RTC.
•We now provide coverage for bariatric surgeries in accordance with our medical policy. Previously, the criteria was listed in the
brochure. (See page 22.)
•We now provide benefits for medically necessary genetic testing for members requesting this service due to susceptibility or
possible high-risk of disease once prior approval has been obtained. Previously, we did not provide benefits for these services. (See
pages 22 and 41.)
•You now must obtain prior approval to receive benefit reimbursement for hearing aids. Previously, prior approval was not required
for hearing aids. (See pages 22 and 55.)
•We no longer require prior approval for the surgical treatment of a congenital anomaly. Previously, prior approval was required.
•We no longer require prior approval for intensity-modulated radiation therapy (IMRT). Previously, IMRT required prior approval
for the treatment of certain cancers.
•We no longer require prior approval for proton beam therapy for members aged 21 and younger, or when care is related to the
treatment of neoplasms of the nervous system including the brain and spinal cord; malignant neoplasms of the thymus; and
Hodgkin and non-Hodgkin lymphomas. Previously, prior approval was required regardless of the age of the patient, or the condition
being treated. (See page 22.)
•We no longer require prior approval for stereotactic radiosurgery related to the treatment of malignant neoplasms of the brain and of
the eye specific to the choroid and ciliary body; benign neoplasms of the cranial nerves, pituitary gland, aortic body, paraganglia;
neoplasms of the craniopharyngeal duct and glomus jugular tumors; trigeminal neuralgias, temporal sclerosis, certain epilepsy
conditions, or arteriovenous malformations. Previously, prior approval was required regardless of the condition being treated. (See
page 22.)
15 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 2
•We now provide coverage for the following artificial insemination (AI) procedures once prior approval has been obtained:
intracervical insemination (ICI), intrauterine insemination (IUI), and intravaginal insemination (IVI) for individuals meeting our
definition of infertility. (See pages 22, 49, and 154.)
•We now provide coverage for breast augmentation for male to female gender affirming care. Previously, we did not list this as a
covered service. (See page 64.)
•We now provide coverage for a mastectomy beginning at the age of 16 for female to male gender affirming care. Previously, we did
not provide benefits until the age of 18. (See page 65.)
•We now require only 6 months of continuous hormone therapy appropriate to the member’s gender identity, unless medically
contraindicated. Previously, we required 12 months of continuous hormone therapy. (See page 65.)
•We have reduced the number of referral letters documenting the diagnosis of gender dysphoria and other criteria to one. Previously,
we required two letters. (See page 65.)
•We now cover certain facial surgeries for gender affirming care and no longer limit covered medically necessary gender affirming
surgical services to once per lifetime. Previously, we did not cover facial gender affirming surgery, and we limited covered
procedures to once per lifetime. (See page 64.)
•We have added the following diagnoses and/or stages of diagnoses to the allogeneic blood or marrow stem cell transplants that do
not require a clinical trial: Blastic plasmacytoid dendritic cell neoplasm; Adrenoleukodystrophy, Globoid cell leukodystrophy
(Krabbe’s leukodystrophy); IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome); Dyskeratosis
congenita; Hypereosinophilic syndromes; plasma cell leukemia; severe congenital neutropenia, common variable
immunodeficiency, chronic granulomatous disease/phagocytic cell disorders; and Systemic mastocytosis, aggressive. Previously,
we did not cover these diagnoses. (See page 68.)
•We have added the following diagnoses and/or stages of diagnoses to the autologous blood or marrow stem cell transplants that do
not require a clinical trial: autoimmune – limited to: idiopathic (juvenile) rheumatoid arthritis, multiple sclerosis (treatment-
refractory relapsing with high risk of future disability) and scleroderma/systemic sclerosis); chronic lymphocytic leukemia (e.g., T
cell prolymphocytic leukemia, B cell prolymphocytic leukemia, hairy cell leukemia); relapsed neuroblastoma; osteosarcoma;
plasma cell leukemia; and Wilms Tumor. Previously, we did not cover these diagnoses, or we required they be done as part of a
clinical trial. (See page 69.)
•We no longer require a clinical trial for allogeneic or autologous bone or marrow stem cell transplants with the following diagnoses:
Multiple Sclerosis and Wilms Tumor.
•We no longer cover allogeneic bone or marrow stem cell transplants with the following diagnoses: colon cancer; epidermolysis
bullosa; glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme); ovarian cancer;
prostate cancer; or autologous bone or marrow transplants for retinoblastoma.
•For allogeneic blood or marrow stem cell transplants, we now cover additional diagnoses only when performed as part of a clinical
trial: autoimmune disease (limited to scleroderma/systemic sclerosis, systemic lupus erythematosus, Idiopathic (juvenile)
rheumatoid arthritis, CIDP (chronic inflammatory demyelinating polyneuropathy); Germ Cell Tumors; high-risk or relapsed
neuroblastoma; lysosomal metabolic diseases: e.g., Mucopolysaccharidosis type II (Hunter syndrome), Mucopolysaccharidosis type
IV (Morquio syndrome), Mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome), Fabry disease, Gaucher disease. (See page
69.)
•For autologous blood or marrow stem cell transplants, we now cover additional diagnoses only when performed as part of a clinical
trial: autoimmune disease (e.g., systemic lupus erythematosus, Crohn’s disease, Polymyositis-dermatomyositis, rheumatoid
arthritis, CIDP (chronic inflammatory demyelinating polyneuropathy); and sarcoma (e.g., rhabdomyosarcoma, soft tissue sarcoma).
Previously, we did not cover transplants for these diagnoses. (See page 70.)
•We now provide coverage for marital and family counseling and psychotherapy services. Previously, we excluded care for these
services. (See page 94.)
•We now provide benefits for drugs associated with covered artificial insemination (AI) procedures. Previously, we did not cover
these drugs when associated with AI procedures. (See pages 103 and 111.)
•We now cover invitro fertilization related drugs limited to three cycles annually once prior approval has been obtained for
individuals that meet our definition of infertility. (See pages 103 and 111.)
•We no longer offer the Diabetes Management Incentive Program. Members who qualified for the program and completed the
program in 2023 will still receive their earned rewards. For more information about the ending of this program, please visit us at
www.fepblue.org.
16 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 2
Section 3. How You Get Care
We will send you an identification (ID) card when you enroll. You should carry your ID card with
you at all times. You will need it whenever you receive services from a covered provider, or fill a
prescription through a Preferred retail pharmacy. Until you receive your ID card, use your copy of
the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter
(for annuitants), or your electronic enrollment system (such as Employee Express) confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if
you need replacement cards, call the Local Plan serving the area where you reside and ask them to
assist you, or write to us directly at: FEP
®
Enrollment Services, 840 First Street NE, Washington,
DC 20065. You may also request replacement cards through our website, www.fepblue.org.
Identification cards
Under Standard Option, you can get care from any “covered professional provider” or “covered
facility provider.” How much we pay – and you pay – depends on the type of covered provider you
use. If you use our Preferred, Participating, or Member providers, you will pay less.
Under Basic Option, you must use those “covered professional providers” or “covered facility
providers” that are Preferred providers for Basic Option in order to receive benefits. Please read
further in this section for exceptions to this requirement.
Under both Standard and Basic Option, you can also get care for the treatment of minor acute
conditions, dermatology care, counseling for behavioral health and substance use disorder, and
nutritional counseling, using teleconsultation services delivered via phone by calling 855-636-1579,
TTY: 711, or via secure online video/messaging at www.fepblue.org/telehealth.
The term “primary care provider” includes family practitioners, general practitioners, medical
internists, pediatricians, obstetricians/gynecologists, and physician assistants. Physician assistants
working for a specialist may also be considered specialists.
Where you get covered
care
FEHB Carriers must have clauses in their in-network (participating) provider agreements. These
clauses provide that, for a service that is a covered benefit in the plan brochure or in some cases for
services determined not medically necessary, the in-network provider agrees to hold the covered
individual harmless (and may not bill) for the difference between the billed charge and the in-
network contracted amount. If an in-network provider bills you for covered services over your
normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its
provider contract.
Balance Billing
Protection
We provide benefits for the services of covered professional providers, as required by Section 2706
(a) of the Public Health Service Act. Covered professional providers within the United States,
Puerto Rico, and the U.S. Virgin Islands are healthcare providers who perform covered services
when acting within the scope of their license or certification under applicable state law and who
furnish, bill, or are paid for their healthcare services in the normal course of business. Covered
services must be provided in the state in which the provider is licensed or certified. If the state has
no applicable licensing or certification requirement, the provider must meet the requirements
of the Local Plan. Your Local Plan is responsible for determining the provider’s licensing status
and scope of practice. As reflected in Section 5, the Plan does limit coverage for some services, in
accordance with accepted standards of clinical practice regardless of the geographic area.
This plan recognizes that transgender, non-binary, and other gender diverse members require
healthcare delivered by healthcare providers experienced in gender affirming health. Benefits
described in this brochure are available to all members meeting medical necessity guidelines
regardless of race, color, national origin, age, disability, religion, sex or gender.
If you have questions about covered providers, would like the names of PPO (Preferred) providers,
or need a Care Coordinator for complex conditions, please contact the Local Plan where services
will be performed.
• Covered professional
providers
17 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
Covered facilities include those listed below, when they meet the state’s applicable licensing or
certification requirements.
Hospital – An institution, or a distinct portion of an institution, that:
1. Primarily provides diagnostic and therapeutic facilities for surgical and medical diagnoses,
treatment, and care of injured and sick persons provided or supervised by a staff of licensed
doctors of medicine (M.D.) or licensed doctors of osteopathy (D.O.), for compensation from its
patients, on an inpatient or outpatient basis;
2. Continuously provides 24-hour-a-day professional registered nursing (R.N.) services; and
3. Is not, other than incidentally, an extended care facility; a nursing home; a place for rest; an
institution for exceptional children, the aged, drug addicts, or alcoholics; or a custodial or
domiciliary institution having as its primary purpose the furnishing of food, shelter, training, or
non-medical personal services.
Note: We consider college infirmaries to be Non-Preferred (Member/Non-member) hospitals. In
addition, we may, at our discretion, recognize any institution located outside the 50 states and the
District of Columbia as a Non-member hospital.
Freestanding Ambulatory Facility – A freestanding facility, such as an ambulatory surgical center,
freestanding surgicenter, freestanding dialysis center, or freestanding ambulatory medical facility,
that:
1. Provides services in an outpatient setting;
2. Contains permanent amenities and equipment primarily for the purpose of performing medical,
surgical, and/or renal dialysis procedures;
3. Provides treatment performed or supervised by doctors and/or nurses, and may include other
professional services performed at the facility; and
4. Is not, other than incidentally, an office or clinic for the private practice of a doctor or other
professional.
Note: We may, at our discretion, recognize any other similar facilities, such as birthing centers, as
freestanding ambulatory facilities.
Residential Treatment Center – Residential treatment centers (RTCs) are licensed by the state,
district, or territory and may be accredited, where required, by a nationally recognized organization
to provide residential treatment for medical conditions, mental health conditions, and/or substance
use disorder. Accredited healthcare facilities (excluding hospitals, skilled nursing facilities, group
homes, halfway houses, and similar types of facilities) provide 24-hour residential evaluation,
treatment and comprehensive specialized services relating to the individual’s medical, physical,
mental health, and/or substance use disorder therapy needs. RTCs offer programs for persons who
need short-term transitional services designed to achieve predicted outcomes focused on fostering
improvement or stability in functional, physical and/or mental health, recognizing the individuality,
strengths, and needs of the persons served. If you have questions about treatment at an RTC or need
assistance coordinating this care, please contact us at the customer service phone number listed on
the back of your ID card.
Blue Distinction
®
Specialty Care
Blue Distinction Specialty Care, our centers of excellence program, focuses on effective treatment
for specialty procedures, such as: Bariatric Surgery, Cardiac Care, Knee and Hip Replacement,
Spine Surgery, Transplants, Cancer Care, Cellular Immunotherapy (CAR-T), Gene Therapy,
Maternity Care, and Substance Use Treatment and Recovery. Using national evaluation criteria
developed with input from medical experts, the Blue Distinction Centers offer comprehensive care
delivered by multidisciplinary teams with subspecialty training and distinguished clinical expertise.
Providers demonstrate quality care, treatment expertise and better overall patient results.
• Covered facility
providers
18 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
We cover specialty care at designated Blue Distinction Centers at Preferred benefit levels. See
Section 5(c) for information regarding enhanced inpatient and outpatient benefits for bariatric,
spine, knee and hip surgeries performed at a Blue Distinction Center. We also provide enhanced
benefits for covered transplant services performed at the Blue Distinction Centers for Transplant
designated centers as described in Section 5(b).
For listings of Blue Distinction Centers, visit https://www.bcbs.com/blue-distinction-center/facility;
access our National Doctor & Hospital Finder via www.fepblue.org/provider/; or call us at the
customer service phone number listed on the back of your ID card.
Cancer Research Facility – A facility that is:
1. A National Cooperative Cancer Study Group institution that is funded by the National Cancer
Institute (NCI) and has been approved by a Cooperative Group as a blood or marrow stem cell
transplant center;
2. An NCI-designated Cancer Center; or
3. An institution that has a peer-reviewed grant funded by the National Cancer Institute (NCI) or
National Institutes of Health (NIH) to study allogeneic or autologous blood or marrow stem cell
transplants.
FACT-Accredited Facility
A facility with a transplant program accredited by the Foundation for the Accreditation of Cellular
Therapy (FACT). FACT-accredited cellular therapy programs meet rigorous standards. Information
regarding FACT transplant programs can be obtained by contacting the transplant coordinator at the
customer service phone number listed on the back of your ID card or by visiting www.factglobal.
org.
Skilled Nursing Facility (SNF)
A SNF is a freestanding institution or a distinct part of a hospital which customarily bills insurance
as a skilled nursing facility and meets the following criteria:
• Is Medicare-certified as a skilled nursing facility;
• Is licensed in accordance with state or local law or is approved by the state or local licensing
agency as meeting the licensing standards (where state or local law provides for the licensing of
such facilities);
• Has a transfer agreement in effect with one or more Preferred hospitals; and
• Is primarily engaged in providing skilled nursing care and related services for patients who
require medical or nursing care; or rehabilitation services for the rehabilitation of injured,
disabled or sick persons.
To be covered, skilled nursing facility care cannot be maintenance or custodial care. The term
skilled nursing facility does not include any institution that is primarily for the care and treatment of
mental diseases. If you have questions about treatment at a SNF, or need assistance coordinating
this care, please contact us at the customer service phone number listed on the back of your ID card.
Other facilities specifically listed in the benefits descriptions in Section 5(c).
19 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
Under Standard Option, you can go to any covered provider you want, but in some circumstances,
we must approve your care in advance.
Under Basic Option, 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 under Basic Option exceptions
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.
What you must do to get
covered care
Specialty care: If you have a chronic or disabling condition and
• 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
• lose access to your Preferred specialist because we terminate our contract with your specialist
for reasons other than for cause,
you may be able to continue seeing your specialist and receiving any Preferred benefits for up to 90
days after you receive notice of the change. Contact us 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.
• Transitional care
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 Service Benefit Plan ID card, you can contact your Local Plan at the phone number listed in
your local phone directory. If you already have your new Service Benefit Plan ID card, call us at the
phone number on the back of the 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.
However, if you changed from another FEHB plan to us, your former plan will pay for the hospital
stay until:
• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92nd day after you become a member of this Plan, whichever happens first.
• If you are
hospitalized when
your enrollment
begins
20 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
These provisions apply only to the benefits of the hospitalized person. If your plan terminates
participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this
continuation of coverage provision does not apply. In such cases, the hospitalized family member’s
benefits under the new plan begin on the effective date of enrollment.
The pre-service claim approval processes for inpatient hospital admissions (called precertification)
and for Other services (called prior approval) are detailed in this Section. A pre-service claim is
any claim, in whole or in part, that requires approval from us before you receive medical care or
services. In other words, a pre-service claim for benefits may require precertification and prior
approval. If you do not obtain precertification, there may be a reduction or denial of benefits. Be
sure to read all of the following precertification and prior approval information. Our FEP medical
policies may be found by visiting www.fepblue.org/policies.
You need prior Plan
approval for certain
services
Precertification is the process by which – prior to your inpatient admission – we evaluate the
medical necessity of your proposed stay, the procedure(s)/service(s) to be performed, the number of
days required to treat your condition, and any applicable benefit criteria. Unless we are misled by
the information given to us, we will not change our decision on medical necessity.
In most cases, your physician or facility will take care of requesting precertification. Because you
are still responsible for ensuring that your care is precertified, you should always ask your
physician, hospital, inpatient residential treatment center, or skilled nursing facility whether or not
they have contacted us and provided all necessary information. You may contact us at the phone
number on the back of your ID card to ask if we have received the request for precertification. Keep
reading this section for information about precertification of an emergency inpatient admission.
• Inpatient hospital
admission, inpatient
residential treatment
center admission, or
skilled nursing
facility admission
We will reduce our benefits for the inpatient hospital stay by $500, even if you have obtained prior
approval for the service or procedure being performed during the stay, if no one contacts us for
precertification. If the stay is not medically necessary, we will not provide benefits for inpatient
hospital room and board or inpatient physician care; we will only pay for covered medical services
and supplies that are otherwise payable on an outpatient basis.
• Warning:
You do not need precertification in these cases:
• You are admitted to a hospital outside the United States; with the exception of admissions for
gender affirming surgery and admissions to residential treatment centers, and skilled nursing
facilities.
• You have another group health insurance policy that is the primary payor for the hospital stay;
with the exception of admissions for gender affirming surgery.
• Medicare Part A is the primary payor for the hospital or skilled nursing facility stay; with the
exception of admissions for gender affirming surgery.
Note: Precertification for covered organ/tissue transplants performed at Blue Distinction
Centers for Transplants is required even if you have another primary group health insurance
policy or have primary Medicare Part A coverage.
Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare
lifetime reserve days, then you do need precertification.
Note: Severe obesity surgery performed during an inpatient stay (even when Medicare Part A is
your primary payor) must meet the surgical requirements listed in our medical policy in order
for benefits to be provided for the admission and surgical procedure.
• Exceptions:
You must obtain prior approval for these services under both Standard and Basic Option in
all outpatient and inpatient settings unless otherwise noted. Precertification is also required if
the service or procedure requires an inpatient hospital admission. Contact us using the
customer service phone number listed on the back of your ID card before receiving these
types of services, and we will request the medical evidence needed to make a coverage
determination:
• Other services
21 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
• Gene therapy and cellular immunotherapy, for example, CAR-T and T-Cell receptor
therapy
• High-cost drugs – We require prior approval for certain high-cost drugs obtained outside of a
pharmacy setting. Contact the customer service number on the back of your ID card or visit us
at www.fepblue.org/highcostdrugs for a list of these drugs.
• Air Ambulance Transport (non-emergent) – Air ambulance transport related to immediate
care of a medical emergency or accidental injury does not require prior approval.
• Outpatient facility-based sleep studies – Prior approval is required for sleep studies
performed in a provider’s office, sleep center, clinic, any type of outpatient center, or any
location other than your home.
• Applied behavior analysis (ABA) – Prior approval is required for ABA and all related
services, including assessments, evaluations, and treatments.
• Gender affirming surgery – Prior to surgical treatment of gender dysphoria, your provider
must submit a treatment plan including all surgeries planned and the estimated date each will be
performed. A new prior approval must be obtained if the treatment plan is approved and your
provider later modifies the plan.
• Genetic testing
• Hearing aids - prior approval is required to receive coverage for hearing aids
• Surgical services – The surgical services on the following list require prior approval for care
performed by Preferred, Participating/Member, and Non-participating/Non-member
professional and facility providers:
- Surgery for severe obesity;
Note: Benefits for the surgical treatment of severe obesity – performed on an inpatient or
outpatient basis – are subject to the pre-surgical requirements listed in our medical policy at
www.fepblue.org/legal/policies-guidelines.
- Surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of
mouth except when care is provided within 72 hours of the accidental injury
• Proton beam therapy – Prior approval is required for all proton beam therapy services except
for members aged 21 and younger, or when related to the treatment of neoplasms of the nervous
system including the brain and spinal cord; malignant neoplasms of the thymus; Hodgkin and
non-Hodgkin lymphomas.
• Stereotactic radiosurgery – Prior approval is required for all stereotactic radiosurgery except
when related to the treatment of malignant neoplasms of the brain, and of the eye specific to the
choroid and ciliary body; benign neoplasms of the cranial nerves, pituitary gland, aortic body, or
paraganglia; neoplasms of the craniopharyngeal duct and glomus jugular tumors; trigeminal
neuralgias, temporal sclerosis, certain epilepsy conditions, or arteriovenous malformations.
• Stereotactic body radiation therapy
• Reproductive Services – Prior approval is required for intracervical insemination (ICI),
intrauterine insemination (IUI), intravaginal insemination (IVI), and assisted reproductive
technologies (ART).
• Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for
individuals facing iatrogenic infertility.
• Hospice care – Prior approval is required for home hospice, continuous home hospice, or
inpatient hospice care services. We will advise you which home hospice care agencies we have
approved.
22 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
• Organ/tissue transplants – Prior approval is required for both the procedure and the facility.
Contact us at the customer service phone number listed on the back of your ID card before
obtaining services. We will request the medical evidence we need to make our coverage
determination. We will consider whether the facility is approved for the procedure and whether
you meet the facility’s criteria.
Some organ transplant procedures listed in Section 5(b) must be performed in a facility with
a Medicare-Approved Transplant Program for the type of transplant anticipated. Transplants
involving more than one organ must be performed in a facility that offers a Medicare-Approved
Transplant Program for each organ transplanted. Contact your local Plan for Medicare’s
approved transplant programs.
If Medicare does not offer an approved program for a certain type of organ transplant
procedure, this requirement does not apply and you may use any covered facility that performs
the procedure. If Medicare offers an approved program for an anticipated organ transplant, but
your facility is not approved by Medicare for the procedure, please contact your Local Plan at
the customer service phone number listed on the back of your ID card.
Some blood or marrow stem cell transplants listed in Section 5(b) must be performed in a
facility with a transplant program accredited by the Foundation for the Accreditation of Cellular
Therapy (FACT), or in a facility designated as a Blue Distinction Center for Transplants or as a
Cancer Research Facility. Other transplant procedures listed in Section 5(b) must be
performed at a FACT-accredited facility. We described these types of facilities earlier in this
section.
Not every transplant program provides transplant services for every type of transplant procedure
or condition listed, or is designated or accredited for every covered transplant. Benefits are not
provided for a covered transplant procedure unless the facility is specifically designated or
accredited to perform that procedure. Before scheduling a transplant, call your Local Plan at the
customer service phone number listed on the back of your ID card for assistance in locating an
eligible facility and requesting prior approval for transplant services.
• Clinical trials for certain blood or marrow stem cell transplants – In Section 5(b) we
provide the list of conditions covered only in clinical trials. Contact us at the customer service
phone number on the back of your ID card for information or to request prior approval before
obtaining services. We will request the medical evidence we need to make our coverage
determination.
Even though we may state benefits are available for a specific type of clinical trial, you may not
be eligible for inclusion in these trials or there may not be any trials available in a Blue
Distinction Center for Transplants to treat your condition. If your physician has recommended
you receive a transplant or that you participate in a transplant clinical trial, we encourage you to
contact the Case Management Department at your Local Plan.
Note: For the purposes of the blood or marrow stem cell clinical trial transplants covered under
this Plan, a clinical trial is a research study whose protocol has been reviewed and approved by
the Institutional Review Board (IRB) of the FACT-accredited facility, Blue Distinction Center
for Transplants, or Cancer Research Facility where the procedure is to be performed.
• Transplant travel – We reimburse costs for transportation (air, rail, bus, and/or taxi) and
lodging if you live 50 miles or more from the facility, up to a maximum of $5,000 per transplant
for the member and companions. If the transplant recipient is age 21 or younger, we pay up to
$10,000 for eligible travel costs for the member and companions. Reimbursement is subject to
IRS regulations.
23 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
• Prescription drugs and supplies – Certain prescription drugs and supplies require prior
approval. Contact CVS Caremark, our Pharmacy Program administrator, at 800-624-5060,
TTY: 711, to request prior approval, or to obtain a list of drugs and supplies that require prior
approval. We will request the information we need to make our coverage determination. You
must periodically renew prior approval for certain drugs. See Section 5(f) for more information
about our prescription drug prior approval program, which is part of our Patient Safety and
Quality Monitoring (PSQM) program.
Please note that updates to the list of drugs and supplies requiring prior approval are made
periodically during the year. New drugs and supplies may be added to the list and prior approval
criteria may change. Changes to the prior approval list or to prior approval criteria are not
considered benefit changes.
Note: Until we approve them, you must pay for these drugs in full when you purchase them –
even if you purchase them at a Preferred retail pharmacy or through our Specialty Drug
Pharmacy Program – and submit the expense(s) to us on a claim form. Preferred pharmacies
will not file these claims for you.
Standard Option members may use our Mail Service Prescription Drug Program to fill their
prescriptions. Basic Option members with primary Medicare Part B coverage also may use this
program once prior approval is obtained.
Note: Neither the Mail Service Prescription Drug Program, nor the Specialty Drug Pharmacy
Program, will fill your prescription for a drug requiring prior approval until you have obtained
prior approval. CVS Caremark, the program administrator, will hold your prescription for you
up to 30 days. If prior approval is not obtained within 30 days, your prescription will be unable
to be filled and a letter will be mailed to you explaining the prior approval procedures.
• Medical foods covered under the pharmacy benefit require prior approval. See Section 5(f)
for more information.
You may request prior approval and receive specific benefit information in advance for non-
emergency surgeries to be performed by Non-participating physicians when the charge for the
surgery will be $5,000 or more. When you contact your local Blue Cross and Blue Shield Plan
before your surgery, the Local Plan will review your planned surgery to determine your coverage,
the medical necessity of the procedure(s), and the Plan allowance for the services. You can call your
Local Plan at the customer service phone number on the back of your ID card.
Note: Standard Option members are not required to obtain prior approval for surgeries performed
by Non-participating providers (unless the surgery is listed in this section as requiring approval –
even if the charge will be $5,000 or more. If you do not call your Local Plan in advance of the
surgery, we will review your claim to provide benefits for the services in accordance with the terms
of your coverage.
• Surgery by Non-
participating
providers under
Standard Option
First, you, your representative, your physician, or your hospital, residential treatment center or other
covered inpatient facility must call us at the phone number listed on the back of your Service
Benefit Plan ID card any time prior to admission or before receiving services that require prior
approval.
Next, provide the following information:
• Enrollee’s name and Plan identification number;
• Patient’s name, birth date, and phone number;
• Reason for inpatient admission, proposed treatment, or surgery;
• Name and phone number of admitting physician;
• Name of hospital or facility;
• Number of days requested for hospital stay; and
• Any other information we may request related to the services to be provided.
How to request
precertification for an
admission or get prior
approval for
Other
services
24 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
Note: If we approve the request for prior approval or precertification, you will be provided with a
notice that identifies the approved services and the authorization period. You must contact us with a
request for a new approval five (5) business days prior to a change to the approved original request,
and for requests for an extension beyond the approved authorization period in the notice you
received. We will advise you of the information needed to review the request for change and/or
extension.
For non-urgent care claims (including non-urgent concurrent care claims), we will tell the physician
and/or hospital the number of approved inpatient days, or the care that we approve for
Other
services
that must have prior approval. We will notify you of our decision within 15 days after the
receipt of the pre-service claim.
If matters beyond our control require an extension of time, we may take up to an additional 15 days
for review and we will notify you of the need for an extension of time before the end of the original
15-day period. Our notice will include the circumstances underlying the request for the extension
and the date when a decision is expected.
If we need an extension because we have not received necessary information from you, our notice
will describe the specific information required and we will allow you up to 60 days from the receipt
of the notice to provide the information.
• Non-urgent care
claims
If you have an urgent care claim (i.e., when waiting for your medical care or treatment could
seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a
physician with knowledge of your medical condition, would subject you to severe pain that cannot
be adequately managed without this care or treatment), we will expedite our review of the claim
and notify you of our decision within 72 hours as long as we receive sufficient information to
complete the review. (For concurrent care claims that are also urgent care claims, please see
If your
treatment needs to be extended
later in this section.) If you request that we review your claim as an
urgent care claim, we will review the documentation you provide and decide whether or not it is an
urgent care claim by applying the judgment of a prudent layperson who possesses an average
knowledge of health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we receive
the claim to let you know what information we need to complete our review of the claim. You will
then have up to 48 hours to provide the required information. We will make our decision on the
claim within 48 hours of (1) the time we received the additional information or (2) the end of the
time frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with written or
electronic notification within three days of oral notification. You may request that your urgent care
claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would
like a simultaneous review of your urgent care claim by OPM either in writing at the time you
appeal our initial decision, or by calling us at the phone number listed on the back of your Service
Benefit Plan ID card. You may also call OPM’s FEHB 1 at 202-606-0727 between 8 a.m. and 5 p.
m. Eastern Time (excluding holidays) to ask for the simultaneous review. We will cooperate with
OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your
claim was a claim for urgent care, call us at the phone number listed on the back of your ID card. If
it is determined that your claim is an urgent care claim, we will expedite our review (if we have not
yet responded to your claim).
• Urgent care claims
A concurrent care claim involves care provided over a period of time or over a number of
treatments. We will treat any reduction or termination of our pre-approved course of treatment
before the end of the approved period of time or number of treatments as an appealable decision.
This does not include reduction or termination due to benefit changes or if your enrollment ends. If
we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and
obtain a decision from us before the reduction or termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to the
expiration of the approved time period and this is also an urgent care claim, we will make a
decision within 24 hours after we receive the request.
• Concurrent care
claims
25 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
If you have an emergency admission due to a condition that you reasonably believe puts your life in
danger or could cause serious damage to bodily function, you, your representative, the physician, or
the hospital must phone us within two business days following the day of the emergency admission,
even if you have been discharged from the hospital. If you do not phone us within two business
days, a $500 penalty may apply – see
Warning
under
Inpatient hospital admissions
earlier in this
Section and
If your facility stay needs to be extended
below.
Admissions to residential treatment centers do not qualify as emergencies.
• Emergency inpatient
admission
You do not need precertification of a maternity admission for a routine delivery. However, if your
medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after
a cesarean section, your physician or the hospital must contact us for precertification of additional
days. Further, if your newborn stays after you are discharged, then your physician or the hospital
must contact us for precertification of additional days for your newborn.
Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the
newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular
medical or surgical benefits apply rather than maternity benefits.
• Maternity care
If your hospital stay – including for maternity and RTC care – needs to be extended, you, your
representative, your physician, or the hospital must ask us to approve the additional days. If you
remain in the hospital beyond the number of days we approved and did not get the additional days
precertified, then:
• for the part of the admission that was medically necessary, we will pay inpatient benefits, but
• for the part of the admission that was not medically necessary, we will pay only medical
services and supplies otherwise payable on an outpatient basis and we will not pay inpatient
benefits.
• If your facility stay
needs to be extended
If you request an extension of an ongoing course of treatment at least 24 hours prior to the
expiration of the approved time period and this is also an urgent care claim, we will make a
decision within 24 hours after we receive the claim.
• If your treatment
needs to be extended
If you have a pre-service claim and you do not agree with our decision regarding
precertification of an inpatient admission or prior approval of
Other services
, you may request a
review by following the procedures listed below. Note that these procedures apply to requests for
reconsideration of concurrent care claims as well. (If you have already received the service, supply,
or treatment, then your claim is a post-service claim and you must follow the entire disputed
claims process detailed in Section 8.)
If you disagree with our
pre-service claim
decision
26 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.
Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
In the case of a pre-service claim and subject to a request for additional information, we have 30
days from the date we receive your written request for reconsideration to:
1. Precertify your inpatient admission or, if applicable, approve your request for prior approval for
the service, drug, or supply; or
2. Write to you and maintain our denial; or
3. Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request.
We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have. We will write
to you with our decision.
• To reconsider a non-
urgent care claim
In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision,
you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims
process detailed in Section 8 of this brochure.
Unless we request additional information, we will notify you of our decision within 72 hours after
receipt of your reconsideration request. We will expedite the review process, which allows verbal or
written requests for appeals and the exchange of information by phone, electronic mail, facsimile,
or other expeditious methods.
• To reconsider an
urgent care claim
After we reconsider your pre-service claim, if you do not agree with our decision, you may ask
OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this
brochure.
• To file an appeal with
OPM
27 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 3
Section 4. Your Costs for Covered Services
This is what you will pay out-of-pocket for your covered care:
Cost-share or cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible,
coinsurance, and copayments) for the covered care you receive.
Note: You may have to pay the deductible, coinsurance, and/or copayment amount(s) that apply to your
care at the time you receive the services.
Cost-share/Cost-
sharing
A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you
receive certain services.
Example: If you have Standard Option when you see your Preferred physician, you pay a copayment of
$30 for the office visit, and we then pay the remainder of the amount we allow for the office visit. (You
may have to pay separately for other services you receive while in the physician’s office.) When you go
into a Preferred hospital, you pay a copayment of $350 per admission. We then pay the remainder of the
amount we allow for the covered services you receive.
Copayments do not apply to services and supplies that are subject to a deductible and/or coinsurance
amount.
Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept
as payment in full) is less than your copayment, you pay the lower amount.
Note: When multiple copayment services are performed by the same professional or facility provider on
the same day, only one copayment applies per provider per day. When the copayment amounts are
different, the highest copayment is applicable. You may be responsible for a separate copayment for
some services.
Example: If you have Basic Option when you visit the outpatient department of a Preferred hospital for
non-emergency treatment services, your copayment is typically $150. If you also receive an ultrasound
in the outpatient department of the same hospital on the same day, you will not be responsible for the
$40 copayment typically applied to the ultrasound.
Copayment
A deductible is a fixed amount of covered expenses you must incur for certain covered services and
supplies before we start paying benefits for them. Copayments and coinsurance amounts do not count
toward your deductible. When a covered service or supply is subject to a deductible, only the Plan
allowance for the service or supply that you then pay counts toward meeting your deductible.
Under Standard Option, the calendar year deductible is $350 per person. After the deductible amount
is satisfied for an individual, covered services are payable for that individual. Under a Self Plus One
enrollment, both family members must meet the individual deductible. Under a Self and Family
enrollment, an individual may meet the individual deductible, or all family members’ individual
deductibles are considered to be satisfied when the family members’ deductibles are combined and
reach $700.
Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept
as payment in full) is less than the remaining portion of your deductible, you pay the lower amount.
Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you
have not paid any amount toward meeting your Standard Option calendar year deductible, you must pay
$80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of
your Standard Option calendar year deductible ($270) has been satisfied.
Note: If you change plans during Open Season and the effective date of your new plan is after January 1
of the next year, you do not have to start a new deductible under your prior plan between January 1 and
the effective date of your new plan. If you change plans at another time during the year, you must begin
a new deductible under your new plan.
Under Basic Option, there is no calendar year deductible.
Deductible
28 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 4
Coinsurance is the percentage of the Plan allowance that you must pay for your care. Your coinsurance
is based on the Plan allowance, or billed amount, whichever is less. Under Standard Option only,
coinsurance does not begin until you have met your calendar year deductible. See Section 5(i) for
information about the deductible and overseas benefits.
Example: You pay 15% of the Plan allowance under Standard Option for durable medical equipment
obtained from a Preferred provider, after meeting your $350 calendar year deductible.
Coinsurance
Note: If your provider routinely waives (does not require you to pay) your applicable deductible
(under Standard Option only), coinsurance, or copayments, the provider is misstating the fee and may
be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the
amount waived.
Example: If your physician ordinarily charges $100 for a service but routinely waives your 35%
Standard Option coinsurance, the actual charge is $65. We will pay $42.25 (65% of the actual charge of
$65).
If your provider
routinely waives your
cost
In some instances, a Preferred, Participating, or Member provider may ask you to sign a “waiver” prior
to receiving care. This waiver may state that you accept responsibility for the total charge for any care
that is not covered by your health plan. If you sign such a waiver, whether or not you are responsible for
the total charge depends on the contracts that the Local Plan has with its providers. If you are asked to
sign this type of waiver, please be aware that, if benefits are denied for the services, you could be
legally liable for the related expenses. If you would like more information about waivers, please contact
us at the customer service phone number on the back of your ID card.
Waivers
Our “Plan allowance” is the amount we use to calculate our payment for certain types of covered
services. Fee-for-service plans arrive at their allowances in different ways, so allowances vary. For
information about how we determine our Plan allowance, see the definition of Plan allowance in
Section 10.
Often, the provider’s bill is more than a fee-for-service plan’s allowance. It is possible for a provider’s
bill to exceed the plan’s allowance by a significant amount. Whether or not you have to pay the
difference between our allowance and the bill will depend on the type of provider you use. Providers
that have agreements with this Plan are Preferred or Participating and will not bill you for any balances
that are in excess of our allowance for covered services. See the descriptions appearing below for the
types of providers available in this Plan.
• Preferred providers. These types of providers have agreements with the Local Plan to limit what
they bill our members. Because of that, when you use a Preferred provider, your share of the
provider’s bill for covered care is limited.
Under Standard Option, your share consists only of your deductible and coinsurance or
copayment. Here is an example about coinsurance: You see a Preferred physician who charges
$250, but our allowance is $100. If you have met your deductible, you are only responsible for your
coinsurance. That is, under Standard Option, you pay just 15% of our $100 allowance ($15).
Because of the agreement, your Preferred physician will not bill you for the $150 difference
between our allowance and the bill.
Under Basic Option, your share consists only of your copayment or coinsurance amount, since
there is no calendar year deductible. Here is an example involving a copayment: You see a Preferred
physician who charges $250 for covered services subject to a $35 copayment. Even though our
allowance may be $100, you still pay just the $35 copayment. Because of the agreement, your
Preferred physician will not bill you for the $215 difference between your copayment and the bill.
Differences between
our allowance and
the bill
29 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 4
• Participating providers. These types of Non-preferred providers have agreements with the Local
Plan to limit what they bill our members.
Under Standard Option, when you use a Participating provider, your share of covered charges
consists only of your deductible and coinsurance or copayment. Here is an example: You see a
Participating physician who charges $250, but the Plan allowance is $100. If you have met your
deductible, you are only responsible for your coinsurance. That is, under Standard Option, you pay
just 35% of our $100 allowance ($35). Because of the agreement, your Participating physician will
not bill you for the $150 difference between our allowance and the bill.
• Non-participating providers. These Non-preferred providers have no agreement to limit what
they will bill you. As a result, your share of the provider’s bill could be significantly more than what
you would pay for covered care from a Preferred provider. If you plan to use a Non-participating
provider for your care, we encourage you to ask the provider about the expected costs and visit our
website, www.fepblue.org, or call us at the customer service phone number on the back of your ID
card for assistance in estimating your total out-of-pocket expenses.
Under Standard Option, when you use a Non-participating provider, you will pay your deductible
and coinsurance – plus any difference between our allowance and the charges on the bill (except in
certain circumstances described in the
No Surprises Act
, later in this section). For example, you see
a Non-participating physician who charges $250. The Plan allowance is again $100, and you have
met your deductible. You are responsible for your coinsurance, so you pay 35% of the $100 Plan
allowance or $35. Plus, because there is no agreement between the Non-participating physician and
us, the physician can bill you for the $150 difference between our allowance and the bill. This
means you would pay a total of $185 ($35 + $150) for the Non-participating physician’s services,
rather than $15 for the same services when performed by a Preferred physician. We encourage you
to always visit Preferred providers for your care. Using Non-participating or Non-member
providers could result in your having to pay significantly greater amounts for the services you
receive.
• Remember, under Basic Option you must use Preferred providers in order to receive benefits.
There are no benefits for care performed by Participating and Non-participating providers.
See Section 3 for exceptions under
What you must do to get covered care
.
The following examples illustrate how much Standard Option members have to pay out-of-pocket for
services performed by Preferred providers, Participating/Member providers, and Non-participating/
Non-member providers. The first example shows services provided by a physician and the second
example shows facility care billed by an ambulatory surgical facility. In both examples, your calendar
year deductible has already been met. Use this information for illustrative purposes only.
Basic Option benefit levels for physician care begin in Section 5(a) and outpatient hospital or
ambulatory surgical facility care begins in Section 5(c).
In the following example, we compare how much you have to pay out-of-pocket for services provided
by a Preferred physician, a Participating physician, and a Non-participating physician. The table uses
our example of a service for which the physician charges $250 and the Plan allowance is $100.
30 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 4
EXAMPLE
Preferred Physician Standard Option
Physician's charge: $250
Our allowance: We set it at: 100
We pay: 85% of our allowance: 85
You owe: Coinsurance: 15% of our allowance: 15
You owe: Copayment: Not applicable
+Difference up to charge?: No: 0
TOTAL YOU PAY: $15
Participating Physician Standard Option
Physician's charge: $250
Our allowance: We set it at: 100
We pay: 65% of our allowance: 65
You owe: Coinsurance: 35% of our allowance: 35
You owe: Copayment: Not applicable
+Difference up to charge?: No: 0
TOTAL YOU PAY: $35
Non-participating Physician Standard Option
Physician's charge: $250
Our allowance: We set it at: 100
We pay: 65% of our allowance: 65
You owe: Coinsurance: 35% of our allowance: 35
You owe: Copayment: Not applicable
+Difference up to charge?: Yes: 150
TOTAL YOU PAY: $185
Note: If you had not met any of your Standard Option deductible in the above example, only our
allowance ($100), which you would pay in full, would count toward your deductible.
You should also see
Important Notice About Surprise Billing – Know Your Rights
in this section that
describes your protections against surprise billing under the No Surprises Act.
In the following example, we compare how much you have to pay out-of-pocket for services billed by a
Preferred, Member, and Non-member ambulatory surgical facility for facility care associated with an
outpatient surgical procedure. The table uses an example of services for which the ambulatory surgical
facility charges $5,000. The Plan allowance is $2,900 when the services are provided at a Preferred or
Member facility, and the Plan allowance is $2,500 when the services are provided at a Non-member
facility.
EXAMPLE
Preferred Ambulatory Surgical Facility Standard Option
Facility’s charge: $5,000
Our allowance: We set it at: 2,900
We pay: 85% of our allowance: 2,465
You owe: Coinsurance: 15% of our allowance: 435
You owe: Copayment: Not applicable
+Difference up to charge?: No: 0
TOTAL YOU PAY: $435
Member Ambulatory Surgical Facility Standard Option
Facility’s charge: $5,000
Our allowance: We set it at: 2,900
We pay: 65% of our allowance: 1,885
You owe: Coinsurance: 35% of our allowance: 1,015
You owe: Copayment: Not applicable
+Difference up to charge?: No: 0
TOTAL YOU PAY: $1,015
31 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 4
Non-member Ambulatory Surgical Facility* Standard Option
Facility’s charge: $5,000
Our allowance: We set it at: 2,500
We pay: 65% of our allowance: 1,625
You owe: Coinsurance: 35% of our allowance: 875
You owe: Copayment: Not applicable
+Difference up to charge?: Yes: 2,500
TOTAL YOU PAY: $3,375
Note: If you had not met any of your Standard Option deductible in the above example, $350 of our
allowed amount would be applied to your deductible before your coinsurance amount was calculated.
*A Non-member facility may bill you any amount for the services it provides. You are responsible
for paying all expenses over our allowance, regardless of the total amount billed, in addition to
your calendar year deductible and coinsurance. For example, if you use a Non-member facility
that charges $60,000 for facility care related to outpatient bariatric surgery, and we pay the
$1,625 amount illustrated above, you would owe $58,375 ($60,000 - $1,625 = $58,375). This
example assumes your calendar year deductible has been met.
The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise
billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency
services provided with respect to a visit to a participating health care facility; and out of network air
ambulance services.
A surprise bill is an unexpected bill you receive for:
• emergency care - when you have little or no say in the facility or provider from whom you receive
care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to
participating healthcare facilities, or for
• air ambulance services furnished by nonparticipating air ambulance providers
Balance billing happens when you receive a bill from the non-participating provider, facility, or air
ambulance service for the difference between the Non-participating provider’s charge and the amount
payable by your health plan.
Your health plan must comply with the NSA protections that hold you harmless from bills.
For specific information on surprise billing, the rights and protections you have, and your
responsibilities go to www.fepblue.org/NSA or contact the customer service phone number on the back
of your ID card.
Important Notice
About Surprise
Billing — Know Your
Rights
Overseas care. Services provided outside the United States, Puerto Rico, and the U.S. Virgin Islands
are considered overseas care. Under Standard and Basic Options, we pay overseas claims at
Preferred benefit levels. Therefore, the Basic Option requirement to use Preferred providers in order to
receive benefits does not apply. See Section 5(i) for specific information about our overseas benefits.
Dental care. Under Standard Option, we pay scheduled amounts for covered dental services and you
pay balances as described in Section 5(g). Under Basic Option, you pay $35 for any covered
evaluation and we pay the balance for covered services. Basic Option members must use Preferred
dentists in order to receive benefits. See Section 5(g) for a listing of covered dental services and
additional payment information.
Inpatient facility care. Under Standard and Basic Options, you pay the coinsurance or copayment
amounts listed in Section 5(c). Under Standard Option, you must meet your deductible before we
begin providing benefits for certain facility-billed services. Under Basic Option, you must use
Preferred facilities in order to receive benefits. See Section 3 under
What you must do to get covered
care
.
Your costs for other
care
32 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 4
Under Standard and Basic Options, we limit your annual out-of-pocket expenses for the covered
services you receive to protect you from unexpected healthcare costs. When your eligible out-of-pocket
expenses reach this catastrophic protection maximum, you no longer have to pay the associated cost-
sharing amounts for the rest of the calendar year. For Self Plus One and Self and Family enrollments,
once any individual family member reaches the Self Only catastrophic protection out-of-pocket
maximum during the calendar year, that member’s claims will no longer be subject to associated cost-
sharing amounts for the rest of the year. All other family members will be required to meet the balance
of the catastrophic protection out-of-pocket maximum.
Note: Certain types of expenses do not accumulate to the maximum.
Standard Option maximums:
Preferred Provider maximum – For a Self Only enrollment, your out-of-pocket maximum for your
deductible, and for eligible coinsurance and copayment amounts, is $6,000 when you use Preferred
providers. For a Self Plus One or Self and Family enrollment, your out-of-pocket maximum for these
types of expenses is $12,000 for Preferred provider services. Only eligible expenses for Preferred
provider services, and the cost-shares associated with care from Non-participating providers under the
NSA, see information earlier in this section, count toward these limits.
Non-preferred Provider maximum – For a Self Only enrollment, your out-of-pocket maximum for
your deductible, and for eligible coinsurance and copayment amounts, is $8,000 when you use Non-
preferred providers. For a Self Plus One or Self and Family enrollment, your out-of-pocket maximum
for these types of expenses is $16,000 for Non-preferred provider services. For either enrollment type,
eligible expenses for the services of Preferred providers also count toward these limits.
Basic Option maximum:
Preferred Provider maximum – For a Self Only enrollment, your out-of-pocket maximum for eligible
coinsurance and copayment amounts is $6,500 when you use Preferred providers. For a Self Plus One
or a Self and Family enrollment, your out-of-pocket maximum for these types of expenses is $13,000
when you use Preferred providers. Only eligible expenses for Preferred provider services count toward
these limits.
The following expenses are not included under this feature. These expenses do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to pay them even after your
expenses exceed the limits described above.
• The difference between the Plan allowance and the billed amount. See earlier information in this
section;
• Expenses for services, drugs, and supplies in excess of our maximum benefit limitations;
• Under Standard Option, your 35% coinsurance for inpatient care in a Non-member facility;
• Under Standard Option, your 35% coinsurance for outpatient care by a Non-member facility;
• Your expenses for dental services in excess of our fee schedule payments under Standard Option.
See Section 5(g);
• The $500 penalty for failing to obtain precertification, and any other amounts you pay because we
reduce benefits for not complying with our cost containment requirements; and
• Under Basic Option, your expenses for care received from Participating/Non-participating
professional providers or Member/Non-member facilities, except for coinsurance and copayments
you pay in those situations where we do pay for care provided by Non-preferred providers. Please
see Section 3,
What you must do to get covered care
, for the exceptions to the requirement to use
Preferred providers.
If your provider’s prescription allows for generic substitution and you select a brand-name drug, your
expenses for the difference in cost-share do not count toward your catastrophic protection out-of-pocket
maximum (see Section 5(f) for additional information).
Your catastrophic
protection out-of-
pocket maximum for
deductibles,
coinsurance, and
copayments
If you change to another plan during Open Season, we will continue to provide benefits between
January 1 and the effective date of your new plan.
Carryover
33 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 4
• If you had already paid the out-of-pocket maximum, we will continue to provide benefits as
described here and previously in this section until the effective date of your new plan.
• If you had not yet paid the out-of-pocket maximum, we will apply any expenses you incur in
January (before the effective date of your new plan) to our prior year’s out-of-pocket maximum.
Once you reach the maximum, you do not need to pay our deductibles, copayments, or coinsurance
amounts (except as previously shown) from that point until the effective date of your new plan.
Because benefit changes are effective January 1, we will apply our next year’s benefits to any expenses
you incur in January.
If you change options in this Plan during the year, we will credit the amounts already accumulated
toward the catastrophic protection out-of-pocket limit of your prior option to the catastrophic protection
out-of-pocket limit of your new option. If you change from Self Only to Self Plus One or Self and
Family, or vice versa, during the calendar year, please call us about your out-of-pocket accumulations
and how they carry over.
We will make diligent efforts to recover benefit payments we made in error but in good faith. We may
reduce subsequent benefit payments to offset overpayments.
We will generally first seek recovery from the provider if we paid the provider directly, or from the
person (covered family member, guardian, custodial parent, etc.) to whom we sent our payment.
If we provided coverage in error, but in good faith, for prescription drugs purchased through one
of our pharmacy programs, we will request reimbursement from the contract holder.
If we overpay you
Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health
Service are entitled to seek reimbursement from us for certain services and supplies they provide to you
or a family member. They may not seek more than their governing laws allow. You may be responsible
to pay for certain services and charges. Contact the government facility directly for more information.
When Government
facilities bill us
Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as
copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and
dental expenses, and much more) for you and your tax dependents, including adult children (through
the end of the calendar year in which they turn 26).
FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP
plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan,
FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim
information it receives from your plan.
The Federal Flexible
Spending Account
Program – FSAFEDS
34 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 4
Section 5. Benefits
Standard and Basic Option
See Section 2 for how our benefits changed this year and towards the end of the brochure for a benefits summary of each option.
Make sure that you review the benefits that are available under the option in which you are enrolled.
Section 5. Standard and Basic Option Overview ........................................................................................................................37
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals ..............................38
Diagnostic and Treatment Services ...................................................................................................................................39
Lab, X-ray and Other Diagnostic Tests .............................................................................................................................40
Preventive Care, Adult ......................................................................................................................................................42
Preventive Care, Child ......................................................................................................................................................44
Maternity Care ..................................................................................................................................................................46
Family Planning ................................................................................................................................................................48
Reproductive Services .......................................................................................................................................................49
Allergy Care ......................................................................................................................................................................50
Treatment Therapies ..........................................................................................................................................................51
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy ................................52
Hearing Services (Testing, Treatment, and Supplies) .......................................................................................................53
Vision Services (Testing, Treatment, and Supplies) .........................................................................................................53
Foot Care ...........................................................................................................................................................................54
Orthopedic and Prosthetic Devices ...................................................................................................................................55
Durable Medical Equipment (DME) .................................................................................................................................56
Medical Supplies ...............................................................................................................................................................57
Home Health Services .......................................................................................................................................................58
Manipulative Treatment ....................................................................................................................................................58
Alternative Treatments ......................................................................................................................................................59
Educational Classes and Programs ...................................................................................................................................59
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals ..........................61
Surgical Procedures ...........................................................................................................................................................62
Reconstructive Surgery .....................................................................................................................................................63
Oral and Maxillofacial Surgery .........................................................................................................................................66
Organ and Tissue Transplants ...........................................................................................................................................67
Anesthesia .........................................................................................................................................................................72
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................74
Inpatient Hospital ..............................................................................................................................................................75
Outpatient Hospital or Ambulatory Surgical Center .........................................................................................................77
Blue Distinction® Specialty Care .....................................................................................................................................81
Residential Treatment Center ............................................................................................................................................82
Extended Care Benefits/Skilled Nursing Care Facility Benefits ......................................................................................83
Hospice Care .....................................................................................................................................................................84
Ambulance ........................................................................................................................................................................87
Section 5(d). Emergency Services/Accidents .............................................................................................................................89
Accidental Injury ...............................................................................................................................................................90
Medical Emergency ..........................................................................................................................................................91
Ambulance ........................................................................................................................................................................92
Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................93
Professional Services ........................................................................................................................................................94
Inpatient Hospital or Other Covered Facility ....................................................................................................................95
Residential Treatment Center ............................................................................................................................................95
Outpatient Hospital or Other Covered Facility .................................................................................................................96
35 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5
Standard and Basic Option
Not Covered (Inpatient or Outpatient) ..............................................................................................................................96
Section 5(f). Prescription Drug Benefits .....................................................................................................................................98
Covered Medications and Supplies .................................................................................................................................114
Section 5(g). Dental Benefits ....................................................................................................................................................121
Accidental Injury Benefit ................................................................................................................................................121
Dental Benefits ................................................................................................................................................................122
Section 5(h). Wellness and Other Special Features ...................................................................................................................125
Health Tools ....................................................................................................................................................................125
Services for the Deaf and Hearing Impaired ...................................................................................................................125
Web Accessibility for the Visually Impaired ...................................................................................................................125
Travel Benefit/Services Overseas ...................................................................................................................................125
Healthy Families .............................................................................................................................................................125
Diabetes Management Program ......................................................................................................................................125
Blue Health Assessment ..................................................................................................................................................125
Hypertension Management Program ..............................................................................................................................126
Pregnancy Care Incentive Program .................................................................................................................................126
Annual Incentive Limitation ...........................................................................................................................................127
Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B .....................................127
MyBlue® Customer eService .........................................................................................................................................127
National Doctor & Hospital Finder .................................................................................................................................127
Care Management Programs ...........................................................................................................................................127
Flexible Benefits Option .................................................................................................................................................128
Telehealth Services .........................................................................................................................................................129
The fepblue Mobile Application .....................................................................................................................................129
Section 5(i). Services, Drugs, and Supplies Provided Overseas ...............................................................................................130
Non-FEHB Benefits Available to Plan Members ......................................................................................................................133
36 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5
Section 5. Standard and Basic Option Overview
Standard and Basic Option
The benefit package for Standard and Basic Options are described in Section 5, which is divided into subsections 5(a) through 5(i).
Make sure that you review the benefits that are available under the option in which you are enrolled.
Please read
Important things you should keep in mind
at the beginning of the subsections. Also read the general exclusions in Section
6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about
Standard and Basic Option benefits, contact us at the customer service phone number on the back of your Service Benefit Plan ID
card or on our website at www.fepblue.org. Each option offers unique features. Members do not need to have referrals to see
specialists.
When you have Standard Option, you can use both Preferred and Non-preferred providers. However,
your out-of-pocket expenses are lower when you use Preferred providers and Preferred providers will
submit claims to us on your behalf. Standard Option has a calendar year deductible for some services
and a $30 copayment for office visits to primary care providers ($40 for specialists). Standard Option
also features a Retail Pharmacy Program, a Mail Service Prescription Drug Program, a Specialty Drug
Pharmacy Program, and the FEP Medicare Prescription Drug Program.
Standard Option
Basic Option does not have a calendar year deductible. Most services are subject to copayments ($35
for primary care providers and $45 for specialists). You must use Preferred providers for your care to be
eligible for benefits, except in certain circumstances, such as emergency care. Preferred providers will
submit claims to us on your behalf. Basic Option also offers the FEP Medicare Prescription Drug
Program, a Retail Pharmacy Program and a Specialty Drug Pharmacy Program. Members with primary
Medicare Part B coverage have access to the Mail Service Prescription Drug Program.
Basic Option
37 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5
Section 5(a). Medical Services and Supplies Provided by Physicians and Other
Healthcare Professionals
Standard and Basic Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
•Please refer to Section 3,
How You Get Care
, for information on covered professional providers and other
healthcare professionals.
•Be sure to read Section 4,
Your Costs for Covered Services
, for valuable information about how cost-sharing
works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age
65 or over.
•We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will
find that some benefits are listed in more than one Section of the brochure. This is because how they are paid
depends on what type of provider or facility bills for the service.
•The services listed in this Section are for the charges billed by a physician or other healthcare professional
for your medical care. See Section 5(c) for charges associated with the facility (i.e., hospital or other
outpatient facility, etc.).
•PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO
benefits apply.
•You should be aware that some Non-preferred (non-PPO) professional providers may provide services in
Preferred (PPO) facilities.
•Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drug
when obtained from a covered provider other than a pharmacy under the pharmacy benefit. This benefit
limitation does not apply if you have primary Medicare Part B coverage or are enrolled in the FEP Medicare
Prescription Drug Program. See Section 5(f) for information about Tier 4 and Tier 5 specialty drug fills from
Preferred providers and Preferred pharmacies. Medications restricted under this benefit are available on our
Specialty Drug List. Visit www.fepblue.org/specialtypharmacy or call us at 888-346-3731.
•Under Standard Option,
- The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment).
- We provide benefits at 85% of the Plan allowance for services provided in Preferred facilities by Non-
preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists,
neonatologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a
physician’s office). You may be responsible for any difference between our payment and the billed
amount. See Section 4, NSA, for information on when you are not responsible for this difference.
•Under Basic Option,
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits. See below and Section 3 for the
exceptions to this requirement.
- We provide benefits at Preferred benefit levels for services provided in Preferred facilities by Non-
preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists,
neonatologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a
physician’s office). You may be responsible for any difference between our payment and the billed
amount. See Section 4, NSA, for information on when you are not responsible for this difference.
38 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit
listed in this Section. There is no calendar year deductible under Basic Option.
Diagnostic and Treatment Services Standard Option Basic Option
Outpatient professional services of physicians and other
healthcare professionals:
• Consultations
• Genetic counseling
• Second surgical opinions
• Clinic visits
• Office visits
• Home visits
• Initial examination of a newborn needing definitive
treatment when covered under a Self Plus One or Self
and Family enrollment
• Pharmacotherapy (medication management) (See
Section 5(f) for prescription drug coverage)
• Phone consultations and online medical evaluation and
management services (telemedicine)
Note: Please refer Section 5(c) for our coverage of these
services when billed for by a facility, such as the outpatient
department of a hospital.
Preferred primary care provider
or other healthcare professional:
$30 copayment per visit (no
deductible)
Preferred specialist: $40
copayment per visit (no
deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred primary care provider
or other healthcare professional:
$35 copayment per visit
Preferred specialist: $45
copayment per visit
Note: You pay 30% of the Plan
allowance for agents, drugs, and/
or supplies administered or
obtained in connection with your
care.
Participating/Non-participating:
You pay all charges
Telehealth professional services for:
• Minor acute conditions
• Dermatology care
Note: Refer to Section 5(h),
Wellness and Other Special
Features
, for information on telehealth services and how to
access a provider.
Note: Benefits are combined with telehealth services listed
in Section 5(e).
Note: Copayments are waived for members with Medicare
Part B primary.
Preferred Telehealth Provider:
Nothing (no deductible) for the
first 2 visits per calendar year for
any covered telehealth service
$10 copayment per visit (no
deductible) after the 2
nd
visit
Participating/Non-participating:
You pay all charges
Preferred Telehealth Provider:
Nothing for the first 2 visits per
calendar year for any covered
telehealth service
$15 copayment per visit after the
2
nd
visit
Participating/Non-participating:
You pay all charges
Inpatient professional services:
• During a covered hospital stay
• Services for nonsurgical procedures when ordered,
provided, and billed by a physician during a covered
inpatient hospital admission
• Medical care by the attending physician (the physician
who is primarily responsible for your care when you are
hospitalized) on days we pay hospital benefits
Note: A consulting physician employed by the hospital is
not the attending physician.
• Consultations when requested by the attending physician
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: Nothing
Participating/Non-participating:
You pay all charges
Diagnostic and Treatment Services - continued on next page
39 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Diagnostic and Treatment Services (cont.) Standard Option Basic Option
• Concurrent care – hospital inpatient care by a physician
other than the attending physician for a condition not
related to your primary diagnosis, or because the
medical complexity of your condition requires this
additional medical care
• Physical therapy by a physician other than the attending
physician
• Initial examination of a newborn needing definitive
treatment when covered under a Self Plus One or Self
and Family enrollment
• Pharmacotherapy (medication management) (See
Section 5(c) for our coverage of drugs you receive while
in the hospital.)
• Second surgical opinion
• Nutritional counseling when billed by a covered
provider
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: Nothing
Participating/Non-participating:
You pay all charges
Not covered:
•
Routine services except for those Preventive care
services described later in this section
•
Costs associated with enabling or maintaining providers'
telehealth (telemedicine) technologies, non-interactive
telecommunication such as email communications, or
asynchronous store-and-forward telehealth services
•
Private duty nursing
•
Standby physicians
•
Routine radiological and staff consultations required by
facility rules and regulations
•
Inpatient physician care when your admission or portion
of an admission is not covered (See Section 5(c).)
Note: If we determine that an inpatient admission is not
covered, we will not provide benefits for inpatient room
and board or inpatient physician care. However, we will
provide benefits for covered services or supplies other than
room and board and inpatient physician care at the level
that we would have paid if they had been provided in some
other setting.
All chargesAll charges
Lab, X-ray and Other Diagnostic Tests Standard Option Basic Option
Diagnostic tests limited to:
• Laboratory tests (such as blood tests and urinalysis)
• Pathology services
• EKGs
Note: See Section 5(c) for services billed for by a facility,
such as the outpatient department of a hospital.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: 15% of the Plan
allowance
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Lab, X-ray and Other Diagnostic Tests - continued on next page
40 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Lab, X-ray and Other Diagnostic Tests (cont.) Standard Option Basic Option
Note: If your Preferred provider
uses a Non-preferred laboratory
or radiologist, we will pay Non-
preferred benefits for any
laboratory and X-ray charges.
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount, in addition
to the Preferred coinsurance
listed under this benefit.
Diagnostic tests including but not limited to:
• Cardiovascular monitoring
• EEGs
• Home-based/unattended sleep studies
• Neurological testing
• Ultrasounds
• X-rays (including set-up of portable X-ray equipment)
Note: See Section 5(c) for services billed for by a facility,
such as the outpatient department of a hospital.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: If your Preferred provider
uses a Non-preferred laboratory
or radiologist, we will pay Non-
preferred benefits for any
laboratory and X-ray charges.
Preferred: $40 copayment
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount in addition
to the Preferred copayment listed
above.
Diagnostic tests limited to:
• Bone density tests
• CT scans/MRIs/PET scans
• Angiographies
• Nuclear medicine
• Facility-based sleep studies (prior approval required)
• Genetic testing (prior approval required)
Note: See Section 5(c) for services billed for by a facility,
such as the outpatient department of a hospital.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: If your Preferred provider
uses a Non-preferred laboratory
or radiologist, we will pay Non-
preferred benefits for any
laboratory and X-ray charges.
Preferred: $100 copayment
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount in addition
to the Preferred copayment listed
above.
41 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Preventive Care, Adult Standard Option Basic Option
Benefits are provided for preventive care services for
adults age 22 and over. Covered services include:
• Counseling on prevention and reducing health risks
• Nutritional counseling
Note: When nutritional counseling is via the contracted
telehealth provider network, we provide benefits as
shown here for Preferred providers. Refer to Section
5(h),
Wellness and Other Special Features
, for
information on how to access a telehealth provider.
• Visits/exams for preventive care
Note: See the definition of Preventive Care, Adult, in
Section 10 for included health screening services.
Preventive care benefits for each of the services listed
below are limited to one per calendar year.
• Administration and interpretation of a Health Risk
Assessment (HRA) questionnaire (see
Definitions
)
Note: As a member of the Service Benefit Plan, you
have access to the Blue Cross and Blue Shield HRA,
called the “Blue Health Assessment” questionnaire. See
Section 5(h) for complete information.
• Basic or comprehensive metabolic panel test
• CBC
• Cervical cancer screening tests
- Human papillomavirus (HPV) tests of cervix
- Pap tests of the cervix
• Colorectal cancer tests, including:
- Colonoscopy, with or without biopsy (see Section 5(b)
for our payment levels for diagnostic colonoscopies)
- CT colonography
- DNA analysis of stool samples
- Double contrast barium enema
- Fecal occult blood test
- Sigmoidoscopy
• Fasting lipoprotein profile (total cholesterol, LDL, HDL,
and/or triglycerides)
• General health panel
• Prostate cancer tests - Prostate Specific Antigen (PSA)
• Screening for chlamydial infection
• Screening for diabetes mellitus
• Screening for gonorrhea infection
• Screening for human immunodeficiency virus (HIV)
• Screening mammograms, including mammography
using digital technology
Preferred: Nothing (no
deductible)
Note: If you receive both
preventive and diagnostic
services from your Preferred
provider on the same day, you are
responsible for paying your cost-
share for the diagnostic services.
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: When billed by a facility,
such as the outpatient department
of a hospital, we provide benefits
as shown here, according to the
contracting status of the facility.
Note: We waive your deductible
and coinsurance amount for
services billed by Participating/
Non-participating providers
related to Influenza (flu)
vaccines. If you use a Non-
participating provider, you pay
any difference between our
allowance and the billed amount.
Preferred: Nothing
Note: If you receive both
preventive and diagnostic
services from your Preferred
provider on the same day, you are
responsible for paying your cost-
share for the diagnostic services.
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount.
Note: When billed by a Preferred
facility, such as the outpatient
department of a hospital, we
provide benefits as shown here
for Preferred providers.
Note: Benefits are not available
for visits/exams for preventive
care, associated laboratory tests,
colonoscopies, or routine
immunizations performed at
Member or Non-member
facilities.
Note: See Section 5(c) for our
payment levels for covered
cancer screenings and ultrasound
screening for abdominal aortic
aneurysm billed for by Member
or Non-member facilities and
performed on an outpatient basis.
Note: We provide benefits for
services billed by Participating/
Non-participating providers
related to Influenza (flu)
vaccines. If you use a Non-
participating provider, you pay
any difference between our
allowance and the billed amount.
Preventive Care, Adult - continued on next page
42 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Preventive Care, Adult (cont.) Standard Option Basic Option
• Ultrasound for abdominal aortic aneurysm for adults,
ages 65 to 75, limited to one screening per lifetime
• Urinalysis
The following preventive services are covered at the time
intervals recommended at each of the links below.
• Immunizations such as COVID-19, Pneumococcal,
influenza, shingles, tetanus/Tdap and human
papillomavirus (HPV). For a complete list of
immunizations, go to the Centers for Disease Control
(CDC) website at https://www.cdc.gov/vaccines/
schedules.
Note: U.S. FDA licensure may restrict the use of the
immunizations and vaccines listed above to certain age
ranges, frequencies, and/or other patient-specific
indications, including gender.
• USPSTF A and B recommended screenings such as
cancer, osteoporosis, depression, and high blood
pressure. For a complete list of covered A and B
recommendation screenings and age and frequency
limitations, go to the U.S. Preventive Services Task
Force (USPSTF) website at https://www.
uspreventiveservicestaskforce.org/uspstf/
recommendation-topics/uspstf-a-and-b-
recommendations.
• Well woman care such as gonorrhea prophylactic
medication to protect newborns, annual counseling for
sexually transmitted infections, contraceptive methods,
and screening for interpersonal and domestic violence.
For a complete list of Well Women preventive care
services, go to the Health and Human Services (HHS)
website at https://www.healthcare.gov/preventive-care-
women/.
• To build your personalized list of preventive services go
to https://health.gov/myhealthfinder.
Note: We pay preventive care benefits on the first claim we
process for each of the above tests you receive in the
calendar year. Regular coverage criteria and benefit levels
apply to subsequent claims for those types of tests if
performed in the same year. If you receive both preventive
and diagnostic services from your Provider on the same
day, you are responsible for paying your cost-share for the
diagnostic services.
Note: Unless otherwise noted, the benefits discussed under
Preventive Care, Adult
, do not apply to individuals aged 21
and younger. (See benefits under
Preventive Care, Child
,
this section.)
Preferred: Nothing (no
deductible)
Note: If you receive both
preventive and diagnostic
services from your Preferred
provider on the same day, you are
responsible for paying your cost-
share for the diagnostic services.
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: When billed by a facility,
such as the outpatient department
of a hospital, we provide benefits
as shown here, according to the
contracting status of the facility.
Note: We waive your deductible
and coinsurance amount for
services billed by Participating/
Non-participating providers
related to Influenza (flu)
vaccines. If you use a Non-
participating provider, you pay
any difference between our
allowance and the billed amount.
Preferred: Nothing
Note: If you receive both
preventive and diagnostic
services from your Preferred
provider on the same day, you are
responsible for paying your cost-
share for the diagnostic services.
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount.
Note: When billed by a Preferred
facility, such as the outpatient
department of a hospital, we
provide benefits as shown here
for Preferred providers.
Note: Benefits are not available
for visits/exams for preventive
care, associated laboratory tests,
colonoscopies, or routine
immunizations performed at
Member or Non-member
facilities.
Note: See Section 5(c) for our
payment levels for covered
cancer screenings and ultrasound
screening for abdominal aortic
aneurysm billed for by Member
or Non-member facilities and
performed on an outpatient basis.
Note: We provide benefits for
services billed by Participating/
Non-participating providers
related to Influenza (flu)
vaccines. If you use a Non-
participating provider, you pay
any difference between our
allowance and the billed amount.
Preventive Care, Adult - continued on next page
43 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Preventive Care, Adult (cont.) Standard Option Basic Option
Note: See Section 5(b) for the benefits available for the
surgical removal of breast, ovaries, or prostate when
screening reveals a BRCA mutation; preventive care
benefits are not available.
Note: Any procedure, injection, diagnostic service,
laboratory, or X-ray service done in conjunction with a
routine examination not included in the preventive
recommended listing of services will be subject to the
applicable member copayments, coinsurance and
deductible.
See previous page See previous page
Not covered:
•
Self-administered health risk assessments (other than the
Blue Health Assessment)
•
Screening services requested solely by the member, such
as commercially advertised heart scans, body scans, and
tests performed in mobile traveling vans
•
Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp,
athletic exams, or travel.
•
Immunizations, boosters, and medications for travel or
work-related exposure. Medical benefits may be
available for these services.
•
Phone consultations and online medical evaluation and
management services (telemedicine) for preventive
services, except as previously noted in this section for
nutritional counseling.
All chargesAll charges
Preventive Care, Child Standard Option Basic Option
Benefits are provided for preventive care services for
children up to age 22. This includes:
• Well-child visits, examinations, and other preventive
services described in the Bright Future Guidelines as
provided by the American Academy of Pediatrics. For a
complete list of the American Academy of Pediatrics
Bright Future Guidelines, go to https://brightfutures.aap.
org.
• Immunizations such as Tdap, Polio, Measles, Mumps,
and Rubella (MMR), and Varicella. For a complete list
of immunizations, go to the Centers for Disease Control
(CDC) website at https://www.cdc.gov/vaccines/
schedules/index.html.
Note: U.S. FDA licensure may restrict the use of the
immunizations and vaccines listed above to specific age
ranges, frequencies, and/or other patient-specific
indications, including gender.
Preferred: Nothing (no
deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: When billed by a facility,
such as the outpatient department
of a hospital, we provide benefits
as shown here, according to the
contracting status of the facility.
Preferred: Nothing
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount.
Note: We provide benefits for
services billed by Participating/
Non-participating providers
related to Influenza (flu)
vaccines. If you use a Non-
participating provider, you pay
any difference between our
allowance and the billed amount.
Preventive Care, Child - continued on next page
44 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Preventive Care, Child (cont.) Standard Option Basic Option
• You may also find a complete list of preventive care
services recommended under the U.S. Preventive
Services Task Force (USPSTF) online at https://www.
uspreventiveservicestaskforce.org/uspstf/
recommendation-topics/uspstf-a-and-b-
recommendations
• To build your personalized list of preventive services, go
to https://health.gov/myhealthfinder.
• Nutritional counseling
Note: Preventive care benefits for each of the services
listed below are limited to one per calendar year.
• Screening for hepatitis B for children age 13 and over
• Screening for chlamydial infection
• Screening for gonorrhea infection
• Cervical cancer screening tests
- Pap tests of the cervix
- Human papillomavirus (HPV) tests of the cervix
• Screening for human immunodeficiency virus (HIV)
infection
• Screening for syphilis infection
• Screening for latent tuberculosis infection for children
ages 18 through 21
Note: If your child receives both preventive and diagnostic
services from a Preferred provider on the same day, you
are responsible for paying the cost-share for the diagnostic
services.
Note: When nutritional counseling is via the contracted
telehealth provider network, we provide benefits as shown
here for Preferred providers. Refer to Section 5(h),
Wellness and Other Special Features
, for information on
how to access a telehealth provider.
Note: Any procedure, injection, diagnostic service,
laboratory, or X-ray service done in conjunction with a
routine examination and not included in the preventive
listing of services will be subject to the applicable member
copayments, coinsurance, and deductible.
Preferred: Nothing (no
deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: When billed by a facility,
such as the outpatient department
of a hospital, we provide benefits
as shown here, according to the
contracting status of the facility.
Note: We waive the deductible
and coinsurance amount for
services billed by Participating
Non-participating providers
related to Influenza (flu)
vaccines. If you use a Non-
participating provider, you pay
any difference between our
allowance and the billed amount.
Preferred: Nothing
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount.
Note: When billed by a facility,
such as the outpatient department
of a hospital, we provide benefits
as shown here, according to the
contracting status of the facility.
Not covered:
•
Self-administered health risk assessments (other than the
Blue Health Assessment)
•
Screening services requested solely by the member, such
as commercially advertised heart scans, body scans, and
tests performed in mobile traveling vans
•
Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp,
athletic exams, or travel
All chargesAll charges
Preventive Care, Child - continued on next page
45 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Preventive Care, Child (cont.) Standard Option Basic Option
•
Immunizations, boosters, and medications for travel or
work-related exposure. Medical benefits may be
available for these services.
•
Phone consultations and online medical evaluation and
management services (telemedicine) for preventive
services, except as noted above for nutritional
counseling.
All chargesAll charges
Maternity Care Standard Option Basic Option
Maternity (obstetrical) care including related conditions
resulting in childbirth or miscarriage, such as:
• Prenatal and postpartum care (including ultrasound,
laboratory, and diagnostic tests)
Note: See Section 5(h) for details about our Pregnancy
Care Incentive Program.
• Delivery
• Assistant surgeons/surgical assistance if required
because of the complexity of the delivery
• Anesthesia (including acupuncture) when requested by
the attending physician and performed by a certified
registered nurse anesthetist (CRNA) or a physician other
than the operating physician (surgeon) or the assistant
• Tocolytic therapy and related services when provided on
an inpatient basis during a covered hospital admission or
during a covered observation stay
• Breastfeeding education and individual coaching on
breastfeeding by healthcare providers such as
physicians, physician assistants, midwives, nurse
practitioners/clinical specialists, and lactation
consultants
• Mental health treatment for postpartum depression and
depression during pregnancy
Note: We provide benefits to cover up to 8 visits per
year in full to treat depression associated with pregnancy
(i.e., depression during pregnancy, postpartum
depression, or both) when you use a Preferred provider.
See Section 5(e) for our coverage of mental health visits
to Non-preferred providers and benefits for additional
mental health services.
Note: See
Preventive Care, Adult
, earlier in this section for
our coverage of nutritional counseling.
Note:
Home Health Services
benefits for home nursing
visits (skilled) related to covered maternity care are subject
to the visit limitations described later in this section.
Note: Maternity care benefits are not provided for
prescription drugs required during pregnancy, except as
recommended under the Affordable Care Act. See Section
5(f) for your prescription drug coverage.
Preferred: Nothing (no
deductible)
Note: For facility care related to
maternity, including care at
birthing facilities, we waive the
per admission copayment and
pay for covered services in full
when you use Preferred
providers.
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: You may request prior
approval and receive specific
benefit information in advance
for the delivery itself and any
other maternity-related surgical
procedures to be provided by a
Non-participating physician
when the charge for that care will
be $5,000 or more. Call your
Local Plan at the customer
service phone number on the
back of your ID card to obtain
information about your coverage
and the Plan allowance for the
services.
Preferred: Nothing
Note: For Preferred facility care
related to maternity, including
care at Preferred birthing
facilities, your responsibility for
covered inpatient services is
limited to $250 per admission.
For outpatient facility services
related to maternity, see the notes
throughout Section 5(c).
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you are responsible
only for any difference between
our allowance and the billed
amount.
Maternity Care - continued on next page
46 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Maternity Care (cont.) Standard Option Basic Option
Note: Here are some things to keep in mind:
• You do not need to precertify your delivery; see Section
3 for other circumstances, such as
extended
stays for you
or your newborn.
• You may remain in the hospital up to 48 hours after a
vaginal delivery and 96 hours after a cesarean delivery.
We will cover an extended stay if medically necessary.
• We cover routine nursery care of the newborn when
performed during the covered portion of the mother’s
maternity stay and billed by the facility. We cover other
care of a newborn who requires professional services or
non-routine treatment, only if we cover the newborn
under a Self Plus One or Self and Family enrollment.
Surgical benefits apply to circumcision when billed by a
professional provider for a male newborn.
• Hospital services are listed in Section 5(c) and Surgical
benefits are in Section 5(b).
Note: See Section 10 for our allowance for inpatient stays
resulting from an emergency delivery at a hospital or other
facility not contracted with your Local Plan.
Note: When a newborn requires definitive treatment during
or after the mother’s confinement, the newborn is
considered a patient in their own right. Regular medical or
surgical benefits apply rather than maternity benefits. See
Section 5(b) for our payment levels for circumcision.
See previous page See previous page
• Breast pump, limited to one per calendar year for
members who are pregnant and/or nursing
• Blood pressure monitor, limited to one every two years
Note: Benefits for the breast pump, milk storage bags, and
blood pressure monitors are only available when you order
them through our fulfillment vendor by visiting www.
fepblue.org/maternity or calling 1-800-411-2583. Milk
storage bags will be included with your breast pump.
Nothing (no deductible) Nothing
Not covered:
•
Procedures, services, drugs, and supplies related to
abortions except when the life of the mother would be
endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or incest
•
Childbirth preparation, Lamaze, and other birthing/
parenting classes
•
Doula, birth companion, and similar supporter
•
Breast pumps and milk storage bags except as
previously noted
•
Breastfeeding supplies other than those contained in the
breast pump kit previously described including clothing
(e.g., nursing bras), baby bottles, or items for personal
comfort or convenience (e.g., nursing pads)
All chargesAll charges
Maternity Care - continued on next page
47 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Maternity Care (cont.) Standard Option Basic Option
•
Tocolytic therapy and related services except as
previously described
•
Maternity care for members not enrolled in the Service
Benefit Plan
All chargesAll charges
Family Planning Standard Option Basic Option
A range of voluntary family planning services for women,
limited to:
• Contraceptive counseling
• Diaphragms and contraceptive rings
• Injectable contraceptives
• Intrauterine devices (IUDs)
• Implantable contraceptives
• Tubal ligation or tubal occlusion/tubal blocking
procedures only
Family planning services for men, limited to:
• Vasectomy
Note: We also provide benefits for professional services
associated with tubal ligation/occlusion/blocking
procedures, vasectomy, and with the fitting, insertion,
implantation, or removal of the contraceptives listed above
at the payment levels shown here.
Note: When billed by a facility, such as the outpatient
department of a hospital, we provide benefits as shown
here, according to the contracting status of the facility.
Preferred: Nothing (no
deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: Nothing
Participating/Non-participating:
You pay all charges
• Oral and transdermal contraceptives
Note: We waive your cost-share for generic oral and
transdermal contraceptives when you purchase them at a
Preferred retail pharmacy or for Standard Option
members and for Basic Option members with primary
Medicare Part B, through the Mail Service Prescription
Drug Program. See Section 5(f) for more information.
Note: When billed by a facility, such as the outpatient
department of a hospital, we provide benefits as shown
here, according to the contracting status of the facility.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: 30% of the Plan
allowance
Participating/Non-participating:
You pay all charges
Not covered:
•
Reversal of voluntary surgical sterilization
•
Contraceptive devices not described above
•
Over-the-counter (OTC) contraceptives, except as
described in Section 5(f)
All chargesAll charges
48 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Reproductive Services Standard Option Basic Option
Members who meet our definition of infertility in Section
10, are eligible for the following reproductive services
once prior approval has been obtained:
• Artificial insemination (AI)
- Intracervical insemination (ICI)
- Intrauterine insemination (IUI)
- Intravaginal insemination (IVI)
Note: We also provide the benefits seen here when these
services are billed by an outpatient facility. See Section 5
(f) (Prescription drug benefits) for your cost-shares
associated with drugs for covered AI procedures.
Note: We cover one year of sperm and egg storage,
including procurement procedures, only for individuals
facing iatrogenic infertility, once per lifetime. We also
provide the benefits seen here when billed by a facility. See
Section 3,
Other services
, for prior approval requirements.
See Section 10 for our definition of iatrogenic infertility.
Note: See other sections in this brochure for benefits
associated with any other services performed to diagnose
and treat the cause of infertility.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: 30% of the Plan
allowance
Participating/Non-participating:
You pay all charges
Assisted reproductive technologies (ART) – Members
who meet our definition of infertility in Section 10 are
eligible for ART services, limited to $25,000 paid annually.
Note: We also provide the benefits seen here when billed
by an outpatient facility.
See Section 5(f),
Prescription Drug Benefits
, for your cost-
shares and limitations for drugs associated with IVF.
Note: The covered AI procedures and associated drugs
listed in this section, and the prescription drugs associated
with ART procedures are not subject to the $25,000 annual
maximum.
Note: Prior approval required.
Preferred: 15% of the Plan
allowance (deductible applies),
and any amount over the $25,000
annual maximum
Participating: 35% of the Plan
allowance (deductible applies),
and any amount over the $25,000
annual maximum
Non-participating: 35% of the
Plan allowance, (deductible
applies), plus any difference
between our allowance and the
billed amount, and any amount
over the $25,000 annual
maximum
All charges
Not covered:
•
All related donor expenses including but not limited to
the cost of donor sperm or oocytes
•
Fallopian tube ligations and vasectomy reversals
•
Services determined to be not medically necessary
•
Other services, supplies, or drugs provided to
individuals not enrolled in this Plan, including
surrogates
All chargesAll charges
49 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Allergy Care Standard Option Basic Option
• Allergy testing
• Allergy treatment
• Sublingual allergy desensitization drugs as licensed by
the U.S. FDA
Note: See earlier in this section for applicable office visit
copayment.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred primary care provider
or other healthcare professional:
$35 copayment
Preferred specialist: $45
copayment
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount.
• Allergy injections
Note: See earlier in this section for applicable office visit
copayment.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: Nothing
Participating/Non-participating:
You pay all charges
• Preparation of each multi-dose vial of antigen
Note: See earlier in this section for applicable office visit
copayment.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred primary care provider
or other healthcare professional:
$35 copayment per multi-dose
vial of antigen
Preferred specialist: $45
copayment per multi-dose vial of
antigen
Participating/Non-participating:
You pay all charges (except as
noted below)
Note: For services billed by Non-
participating laboratories or
radiologists, you pay any
difference between our allowance
and the billed amount.
Not covered: Provocative food testingAll chargesAll charges
50 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Treatment Therapies Standard Option Basic Option
Outpatient treatment therapies:
• Chemotherapy and radiation therapy
Note: We cover high-dose chemotherapy and/or
radiation therapy in connection with bone marrow
transplants, and drugs or medications to stimulate or
mobilize stem cells for transplant procedures, only for
those conditions listed as covered under
Organ/Tissue
Transplants
in Section 5(b). See also,
Other services
under
You need prior Plan approval for certain services
in Section 3.
Note: You must get prior approval for certain
radiation therapy treatments. Please refer to Section 3
for more information.
• Renal dialysis – Hemodialysis and peritoneal dialysis
• Intravenous (IV)/infusion therapy – Home IV or infusion
therapy
Note: Home nursing visits associated with Home IV/
infusion therapy are covered as shown under
Home
Health Services
later in this section.
• Outpatient cardiac rehabilitation
• Pulmonary rehabilitation therapy
• Applied behavior analysis (ABA) for the treatment of an
autism spectrum disorder (see prior approval
requirements in Section 3)
Note: See Section 5(c) for our payment levels for treatment
therapies billed for by the outpatient department of a
hospital.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred primary care provider
or other healthcare professional:
$35 copayment per visit
Preferred specialist: $45
copayment per visit
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Participating/Non-participating:
You pay all charges
• Auto-immune infusion medications: Remicade,
Renflexis and Inflectra
Note: See above for your costs for intravenous (IV)/
infusion therapy - Home IV or infusion therapy.
Preferred: 10% of the Plan
allowance (deductible applies)
Participating: 15% of the Plan
allowance (deductible applies)
Non-participating: 15% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and billed
amount
Preferred: 15% of the Plan
allowance
Participating/Non-participating:
You pay all charges
Treatment Therapies - continued on next page
51 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Treatment Therapies (cont.) Standard Option Basic Option
Inpatient treatment therapies:
• Chemotherapy and radiation therapy
Note: We cover high-dose chemotherapy and/or
radiation therapy in connection with bone marrow
transplants, and drugs or medications to stimulate or
mobilize stem cells for transplant procedures, only for
those conditions listed as covered under
Organ/Tissue
Transplants
in Section 5(b). See also
Other services
under
You need prior Plan approval for certain services
in Section 3.
• Renal dialysis – Hemodialysis and peritoneal dialysis
• Pharmacotherapy (medication management) (See
Section 5(c) for our coverage of drugs administered in
connection with these treatment therapies.)
• Applied behavior analysis (ABA) for the treatment of an
autism spectrum disorder (see prior approval
requirements in Section 3)
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: Nothing
Participating/Non-participating:
You pay all charges
Physical Therapy, Occupational Therapy,
Speech Therapy, and Cognitive Rehabilitation
Therapy
Standard Option Basic Option
• Physical therapy, occupational therapy, and speech
therapy
• Cognitive rehabilitation therapy
Note: When billed by a skilled nursing facility, nursing
home, extended care facility, or residential treatment
center, we pay benefits as shown here for professional care,
according to the contracting status of the facility.
Preferred primary care provider
or other healthcare professional:
$30 copayment per visit (no
deductible)
Preferred specialist: $40
copayment per visit (no
deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: Benefits are limited to 75
visits per person, per calendar
year for physical, occupational,
or speech therapy, or a
combination of all three.
Note: Visits that you pay for
while meeting your calendar year
deductible count toward the limit
cited above.
Preferred primary care provider
or other healthcare professional:
$35 copayment per visit
Preferred specialist: $45
copayment per visit
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Note: Benefits are limited to 50
visits per person, per calendar
year for physical, occupational,
or speech therapy, or a
combination of all three.
Participating/Non-participating:
You pay all charges
Note: See Section 5(c) for our
payment levels for rehabilitative
therapies billed for by the
outpatient department of a
hospital.
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy - continued on next page
52 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Physical Therapy, Occupational Therapy,
Speech Therapy, and Cognitive Rehabilitation
Therapy (cont.)
Standard Option Basic Option
Not covered:
•
Recreational or educational therapy, and any related
diagnostic testing except as provided by a hospital as
part of a covered inpatient stay
•
Maintenance or palliative rehabilitative therapy
•
Exercise programs
•
Equine therapy and hippotherapy (exercise on
horseback)
•
Massage therapy
All chargesAll charges
Hearing Services (Testing, Treatment, and
Supplies)
Standard Option Basic Option
• Hearing tests related to illness or injury
• Testing and examinations for prescribing hearing aids
Note: For our coverage of hearing aids and related
services, see
Orthopedic and Prosthetic Devices
in this
section.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred primary care provider
or other healthcare professional:
$35 copayment per visit
Preferred specialist: $45
copayment per visit
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Participating/Non-participating:
You pay all charges
Not covered:
•
Routine hearing tests
•
Hearing aids (except as described later in this section)
All chargesAll charges
Vision Services (Testing, Treatment, and
Supplies)
Standard Option Basic Option
Benefits are limited to one pair of eyeglasses, replacement
lenses, or contact lenses per incident prescribed:
• To correct an impairment directly caused by a single
instance of accidental ocular injury or intraocular
surgery;
• If the condition can be corrected by surgery, but surgery
is not an appropriate option due to age or medical
condition;
• For the nonsurgical treatment for amblyopia and
strabismus, for children from birth through age 21
Note: Benefits are provided for refractions only when the
refraction is performed to determine the prescription for
the one pair of eyeglasses, replacement lenses, or contact
lenses provided per incident as previously described.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: 30% of the Plan
allowance
Participating/Non-participating:
You pay all charges
Vision Services (Testing, Treatment, and Supplies) - continued on next page
53 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Vision Services (Testing, Treatment, and
Supplies) (cont.)
Standard Option Basic Option
• Eye examinations related to a specific medical condition
• Nonsurgical treatment for amblyopia and strabismus, for
children from birth through age 21
Note: See Section 5(b), Surgical procedures, for coverage
for surgical treatment of amblyopia and strabismus.
Note: See earlier in this section for our payment levels for
Lab, X-ray, and other diagnostic tests performed or ordered
by your provider.
Preferred primary care provider
or other healthcare professional:
$30 copayment (no deductible)
Preferred specialist: $40
copayment (no deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred primary care provider
or other healthcare professional:
$35 copayment per visit
Preferred specialist: $45
copayment per visit
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Participating/Non-participating:
You pay all charges
Not covered:
•
Eyeglasses, contact lenses, routine eye examinations, or
vision testing for the prescribing or fitting of eyeglasses
or contact lenses, except as previously described
•
Deluxe eyeglass frames or lens features for eyeglasses or
contact lenses such as special coating, polarization, UV
treatment, etc.
•
Multifocal, accommodating, toric, or other premium
intraocular lenses (IOLs) including Crystalens, ReStor,
and ReZoom
•
Eye exercises, visual training, or orthoptics, except for
nonsurgical treatment of amblyopia and strabismus as
described above
•
LASIK, INTACS, radial keratotomy, and other refractive
surgical services
•
Refractions, including those performed during an eye
examination related to a specific medical condition,
except as described above
All chargesAll charges
Foot Care Standard Option Basic Option
Routine foot care when you are under active treatment for
a metabolic or peripheral vascular disease, such as diabetes
Note: See
Orthopedic and Prosthetic Devices
for
information on podiatric shoe inserts.
Note: See Section 5(b) for our coverage for surgical
procedures.
Preferred primary care provider
or other healthcare professional:
$30 copayment for the office visit
(no deductible); 15% of the Plan
allowance for all other services
(deductible applies)
Preferred specialist: $40
copayment for the office visit (no
deductible); 15% of the Plan
allowance for all other services
(deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Preferred primary care provider
or other healthcare professional:
$35 copayment per visit
Preferred specialist: $45
copayment per visit
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Participating/Non-participating:
You pay all charges
Foot Care - continued on next page
54 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Foot Care (cont.) Standard Option Basic Option
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Not covered: Routine foot care, such as cutting, trimming,
or removal of corns, calluses, or the free edge of toenails,
and similar routine treatment of conditions of the foot,
except as stated above
All chargesAll charges
Orthopedic and Prosthetic Devices Standard Option Basic Option
Orthopedic braces and prosthetic appliances such as:
• Artificial limbs and eyes
• Functional foot orthotics when prescribed by a physician
• Rigid devices attached to the foot or a brace, or placed in
a shoe
• Replacement, repair, and adjustment of covered devices
• Following a mastectomy, breast prostheses and surgical
bras, including necessary replacements
• Surgically implanted penile prostheses limited to
treatment of erectile dysfunction or as part of an
approved plan for gender affirming surgery
• Surgical implants
Note: A prosthetic appliance is a device that is surgically
inserted or physically attached to the body to restore a
bodily function or replace a physical portion of the body.
We provide hospital benefits for internal prosthetic
devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implants
following mastectomy; see Section 5(c) for payment
information. Insertion of the device is paid as surgery; see
Section 5(b).
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: 30% of the Plan
allowance
Participating/Non-participating:
You pay all charges
• Hearing aids for children up to age 22, limited to $2,500
per calendar year
• Hearing aids for adults age 22 and over, limited to
$2,500 every 5 calendar years
Note: Benefits for hearing aid dispensing fees, fittings,
batteries, and repair services are included in the benefit
limits described above. Prior approval is required for
hearing aids.
Any amount over $2,500 (no
deductible)
Any amount over $2,500
• Bone-anchored hearing aids when medically necessary,
limited to $5,000 per calendar year
Any amount over $5,000 (no
deductible)
Any amount over $5,000
• Wigs for hair loss due to the treatment of cancer
Note: Benefits for wigs are paid at 100% of the billed
amount, limited to $350 for one wig per lifetime.
Any amount over $350 for one
wig per lifetime (no deductible)
Any amount over $350 for one
wig per lifetime
Orthopedic and Prosthetic Devices - continued on next page
55 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Orthopedic and Prosthetic Devices (cont.) Standard Option Basic Option
Not covered:
•
Shoes (including diabetic shoes)
•
Over-the-counter orthotics
•
Arch supports
•
Heel pads and heel cups
•
Wigs (including cranial prostheses), except for scalp hair
prosthesis for hair loss due to the treatment of cancer, as
stated above
•
Over the counter hearing aids, enhancement devices,
accessories or supplies (including remote controls and
warranty packages), and hearing aids when prior
approval was not obtained
All chargesAll charges
Durable Medical Equipment (DME) Standard Option Basic Option
Durable medical equipment (DME) is equipment and
supplies that are:
1. Prescribed by your attending physician (i.e., the
physician who is treating your illness or injury);
2. Medically necessary;
3. Primarily and customarily used only for a medical
purpose;
4. Generally useful only to a person with an illness or
injury;
5. Designed for prolonged use; and
6. Used to serve a specific therapeutic purpose in the
treatment of an illness or injury.
We cover rental or purchase of durable medical equipment,
at our option, including repair and adjustment. Covered
items include:
• Home dialysis equipment
• Oxygen equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Continuous passive motion (CPM) devices
• Dynamic orthotic cranioplasty (DOC) devices
• Insulin pumps
• Other items that we determine to be DME, such as
compression stockings
Note: We cover DME at Preferred benefit levels only when
you use a Preferred DME provider. Preferred physicians,
facilities, and pharmacies are not necessarily Preferred
DME providers.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: 30% of the Plan
allowance
Participating/Non-participating:
You pay all charges
Durable Medical Equipment (DME) - continued on next page
56 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Durable Medical Equipment (DME) (cont.) Standard Option Basic Option
• Speech-generating devices, limited to $1,250 per
calendar year
Any amount over $1,250 per year
(no deductible)
Any amount over $1,250 per year
Not covered:
•
Exercise and bathroom equipment
•
Vehicle modifications, replacements, or upgrades
•
Home modifications, upgrades, or additions
•
Lifts, such as seat, chair, or van lifts
•
Car seats
•
Diabetic supplies , except as described in Section 5(f) or
when Medicare Part B is primary
•
Air conditioners, humidifiers, dehumidifiers, and
purifiers
•
Breast pumps, except as previously described
•
Communications equipment, devices, and aids
(including computer equipment) such as “story boards”
or other communication aids to assist communication-
impaired individuals (except for speech-generating
devices as listed above)
•
Equipment for cosmetic purposes
•
Topical Hyperbaric Oxygen Therapy (THBO)
•
Charges associated with separate or extended warranties
All chargesAll charges
Medical Supplies Standard Option Basic Option
• Medical foods and nutritional supplements when
administered by catheter or nasogastric tubes
Note: See Section 10,
Definitions
, for more information
about medical foods.
• Ostomy and catheter supplies
• Oxygen
Note: When billed by a skilled nursing facility, nursing
home, or extended care facility, we pay benefits as
shown here for oxygen, according to the contracting
status of the facility.
• Blood and blood plasma, except when donated or
replaced, and blood plasma expanders
Note: We cover medical supplies at Preferred benefit levels
only when you use a Preferred medical supply provider.
Preferred physicians, facilities, and pharmacies are not
necessarily Preferred medical supply providers.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: 30% of the Plan
allowance
Participating/Non-participating:
You pay all charges
Not covered:
•
Infant formulas used as a substitute for breastfeeding
•
Diabetic supplies , except as described in Section 5(f) or
when Medicare Part B is primary, or are enrolled in the
FEP Medicare Prescription Drug Program
All chargesAll charges
Medical Supplies - continued on next page
57 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Medical Supplies (cont.) Standard Option Basic Option
•
Medical foods administered orally, except as described
in Section 5(f)
All chargesAll charges
Home Health Services Standard Option Basic Option
Home nursing care (skilled) for two hours per day when:
• A registered nurse (R.N.) or licensed practical nurse
(L.P.N.) provides the services; and
• A physician orders the care
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: Benefits for home nursing
care are limited to 50 visits per
person, per calendar year.
Note: Visits that you pay for
while meeting your calendar year
deductible count toward the
annual visit limit.
Preferred: $35 copayment per
visit
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered or
obtained in connection with your
care.
Note: Benefits for home nursing
care are limited to 25 visits per
person, per calendar year.
Participating/Non-participating:
You pay all charges
Not covered:
•
Nursing care requested by, or for the convenience of, the
patient or the patient’s family
•
Services primarily for bathing, feeding, exercising,
moving the patient, homemaking, giving medication, or
acting as a companion or sitter
•
Services provided by a nurse, nursing assistant, health
aide, or other similarly licensed or unlicensed person
that are billed by a skilled nursing facility, extended care
facility, or nursing home, except as described in Section
5(c) under Skilled Nursing Care.
•
Private duty nursing
All chargesAll charges
Manipulative Treatment Standard Option Basic Option
Manipulative treatment performed by a professional
provider, when the provider is practicing within the scope
of his/her license, limited to:
• Osteopathic manipulative treatment to any body region
• Chiropractic spinal and/or extraspinal manipulative
treatment
Note: Benefits for manipulative treatment are limited to the
services and combined treatment visits stated here.
Note: When billed by a facility, such as the outpatient
department of a hospital, we provide benefits as shown
here, according to the contracting status of the facility.
Preferred: $30 copayment per
visit (no deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: $35 copayment per
visit
Note: Benefits for osteopathic
and chiropractic manipulative
treatment are limited to a
combined total of 20 visits per
person, per calendar year.
Participating/Non-participating:
You pay all charges
Manipulative Treatment - continued on next page
58 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Manipulative Treatment (cont.) Standard Option Basic Option
Note: Benefits for osteopathic
and chiropractic manipulative
treatment are limited to a
combined total of 12 visits per
person, per calendar year.
Note: Manipulation visits that
you pay for while meeting your
calendar year deductible count
toward the treatment limit cited
above.
Alternative Treatments Standard Option Basic Option
Acupuncture
Note: Acupuncture must be performed and billed by a
healthcare provider who is licensed or certified to perform
acupuncture by the state where the services are provided,
and who is acting within the scope of that license or
certification. See
Covered professional providers
in
Section 3.
Note: When billed by a facility such as the outpatient
department of a hospital, you are limited to the number of
visits per calendar year listed on this page. See Section 5(c)
for your cost-share.
Note: See Section 5(b) for our coverage of acupuncture
when provided as anesthesia for covered surgery.
Note: See earlier in this section for our coverage of
acupuncture when provided as anesthesia for covered
maternity care.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: Benefits for acupuncture
are limited to 24 visits per
calendar year.
Note: Visits that you pay for
while meeting your calendar year
deductible count toward the limit
cited above.
Preferred primary care provider
or other healthcare professional:
$35 copayment per visit
Preferred specialist: $45
copayment per visit
Note: Benefits for acupuncture
are limited to 12 visits per
calendar year.
Note: You pay 30% of the Plan
allowance for drugs and supplies.
Participating/Non-participating:
You pay all charges
Not covered:
•
Biofeedback
•
Self-care or self-help training
All chargesAll charges
Educational Classes and Programs Standard Option Basic Option
• Smoking and tobacco cessation treatment
- Counseling for smoking and tobacco cessation
- Smoking and tobacco cessation classes
Note: See Section 5(f) for our coverage of smoking
and tobacco cessation drugs.
Preferred: Nothing (no
deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: Nothing
Participating/Non-participating:
You pay all charges
Educational Classes and Programs - continued on next page
59 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Standard and Basic Option
Benefit Description You Pay
Educational Classes and Programs (cont.) Standard Option Basic Option
• Diabetic education
Note: See earlier references for our coverage of
nutritional counseling services that are not part of a
diabetic education program.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred primary care provider
or other healthcare professional:
$35 copayment per visit
Preferred specialist: $45
copayment per visit
Participating/Non-participating:
You pay all charges
Not covered:
•
Educational, or other counseling or training services, or
applied behavior analysis (ABA), when performed as
part of an educational class or program
•
Premenstrual syndrome (PMS), lactation , headache,
eating disorder, and other educational clinics unless
described earlier in this section as being covered
•
Recreational or educational therapy, and any related
diagnostic testing except as provided by a hospital as
part of a covered inpatient stay
•
Services performed or billed by a school or halfway
house or a member of its staff
All chargesAll charges
60 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(a)
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and
Other Healthcare Professionals
Standard and Basic Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
•Be sure to read Section 4,
Your Costs for Covered Services
, for valuable information about how cost-sharing
works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age
65 or over.
•We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will
find that some benefits are listed in more than one Section of the brochure. This is because how they are paid
depends on what type of provider bills for the service.
•The services listed in this Section are for the charges billed by a physician or other healthcare professional
for your surgical care. See Section 5(c) for charges associated with a facility (i.e., hospital, surgical center,
etc.).
•YOU MUST GET PRIOR APPROVAL for the following surgical services: surgery for severe obesity;
and surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth,
except when care is provided within 72 hours of the accidental injury. Please refer to Section 3 for
more information.
•YOU MUST GET PRIOR APPROVAL for all organ transplant surgical procedures (except corneal
transplants); and if your surgical procedure requires an inpatient admission, YOU MUST GET
PRECERTIFICATION. Please refer to the prior approval and precertification information shown in
Section 3 to be sure which services require prior approval or precertification.
•YOU MUST GET PRIOR APPROVAL for gender affirming surgery. Prior to any gender affirming
surgery, your provider must submit a treatment plan including all surgeries planned and the estimated
date each will be performed. A new prior approval must be obtained if the treatment plan is approved
and your provider later modifies the plan (including changes to the procedures to be performed or the
anticipated dates for the procedures). See Section 3 and later in this section for additional information.
If your surgical procedure requires an inpatient admission, YOU MUST ALSO GET
PRECERTIFICATION of the inpatient care.
•PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO
benefits apply.
•Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drug
when obtained from a covered provider other than a pharmacy under the pharmacy benefit. This benefit
limitation does not apply if you have primary Medicare Part B coverage or are enrolled in the FEP Medicare
Prescription Drug Program. See Section 5(f) for information about Tier 4 and Tier 5 specialty drug fills from
Preferred providers and Preferred pharmacies. Medications restricted under this benefit are available on our
Specialty Drug List. Visit www.fepblue.org/specialtypharmacy or call us at 888-346-3731.
•Under Standard Option,
- The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment).
- We provide benefits at 85% of the Plan allowance for services provided in Preferred facilities by Non-
preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists,
neonatologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a
physician’s office). You may be responsible for any difference between our payment and the billed
amount. See Section 4, NSA, for information on when you are not responsible for this difference.
- You may request prior approval and receive specific benefit information in advance for surgeries to be
performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See
Section 3 for more information.
61 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
•Under Basic Option,
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits. See below and Section 3 for the
exceptions to this requirement.
- We provide benefits at Preferred benefit levels for services provided in Preferred facilities by Non-
preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists,
neonatologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a
physician’s office). You may be responsible for any difference between our payment and the billed
amount. See Section 4, NSA, for information on when you are not responsible for this difference.
Benefit Description You Pay
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit
listed in this Section. There is no calendar year deductible under Basic Option.
Surgical Procedures Standard Option Basic Option
A comprehensive range of services, such as:
• Operative procedures
• Assistant surgeons/surgical assistance if required because of
the complexity of the surgical procedures
• Treatment of fractures and dislocations, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Colonoscopy, with or without biopsy
Note: Preventive care benefits apply to the professional
charges for your first covered colonoscopy of the calendar
year, see Section 5(a). We provide benefits as described here
for subsequent colonoscopy procedures performed by a
professional provider in the same year.
• Endoscopic procedures
• Injections
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies
• Treatment of burns
• Male circumcision
• Insertion of internal prosthetic devices. See Section 5(a),
Orthopedic and Prosthetic Devices
, and Section 5(c),
Other
Hospital Services and Supplies
, for our coverage for the
device.
• Procedures to treat severe obesity when you meet the
clinical criteria in our medical policy at www.fepblue.org/
legal/policies-guidelines for any initial and subsequent
surgery (prior approval required).
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: You may request prior
approval and receive specific
benefit information in advance
for surgeries to be performed
by Non-participating
physicians when the charge for
the surgery will be $5,000 or
more. See Section 3 for more
information.
Preferred: $150 copayment per
performing surgeon, for
surgical procedures performed
in an office setting
Preferred: $200 copayment per
performing surgeon, for
surgical procedures performed
in all other settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact
the provider if you have any
questions about the place of
service.
Note: If you receive the
services of a co-surgeon, you
pay a separate copayment for
those services, based on where
the surgical procedure is
performed. No additional
copayment applies to the
services of assistant surgeons.
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered
or obtained in connection with
your care.
Participating/Non-
participating: You pay all
charges
Surgical Procedures - continued on next page
62 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Surgical Procedures (cont.) Standard Option Basic Option
Note: When multiple surgical procedures that add time or
complexity to patient care are performed during the same
operative session, the Local Plan determines our allowance for
the combination of multiple, bilateral, or incidental surgical
procedures. Generally, we will allow a reduced amount for
procedures other than the primary procedure.
Note: We do not pay extra for “incidental” procedures (those
that do not add time or complexity to patient care).
Note: When unusual circumstances require the removal of casts
or sutures by a physician other than the one who applied them,
the Local Plan may determine that a separate allowance is
payable.
See prior page See prior page
Not covered:
•
Reversal of voluntary sterilization
•
Services of a standby physician
•
Routine surgical treatment of conditions of the foot (see
Section 5(a), Foot Care)
•
Cosmetic surgery
•
LASIK, INTACS, radial keratotomy, and other refractive
surgery
•
Surgeries related to sexual inadequacy (except surgical
placement of penile prostheses to treat erectile dysfunction
and gender affirming surgeries specifically listed as covered)
•
Reversal of gender affirming surgery
All chargesAll charges
Reconstructive Surgery Standard Option Basic Option
• Surgery to correct a functional defect
• Surgery to correct a congenital anomaly
• Treatment to restore the mouth to a pre-cancer state
• All stages of breast reconstruction surgery following a
mastectomy, such as:
- Surgery to produce a symmetrical appearance of the
patient’s breasts
- Treatment of any physical complications, such as
lymphedemas
Note: Internal breast prostheses are paid as orthopedic and
prosthetic devices; see Section 5(a). See Section 5(c) when
billed by a facility.
Note: If you need a mastectomy, you may choose to have
the procedure performed on an inpatient basis and remain
in the hospital up to 48 hours after the procedure.
• Surgery for placement of penile prostheses to treat erectile
dysfunction
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: You may request prior
approval and receive specific
benefit information in advance
for surgeries to be performed
by Non-participating
physicians when the charge for
the surgery will be $5,000 or
more. See Section 3 for more
information.
Preferred: $150 copayment per
performing surgeon, for
surgical procedures performed
in an office setting
Preferred: $200 copayment per
performing surgeon, for
surgical procedures performed
in all other settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact
the provider if you have any
questions about the place of
service.
Reconstructive Surgery - continued on next page
63 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Reconstructive Surgery (cont.) Standard Option Basic Option
See previous page Continued from previous page:
Note: If you receive the
services of a co-surgeon, you
pay a separate copayment for
those services, based on where
the surgical procedure is
performed. No additional
copayment applies to the
services of assistant surgeons.
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered
or obtained in connection with
your care.
Participating/Non-
participating: You pay all
charges
• Gender affirming surgical benefits are limited to the
following:
- For female to male surgery: mastectomy (including nipple
reconstruction), hysterectomy, vaginectomy, salpingo-
oophorectomy, metoidioplasty, phalloplasty, urethroplasty,
scrotoplasty, facial gender affirming surgery (limited to
forehead lengthening, cheek augmentation, rhinoplasty, jaw
reshaping, chin contouring, Adam’s apple enhancement
(thyroid cartilage enhancement or implant), pitch lowering
masculinization voice surgery, cosmetic fillers, botulinum
toxin, fat grafting, and liposuction), electrolysis (hair
removal at the covered operative site), and placement of
testicular and erectile prosthesis
- For male to female surgery: penectomy, orchiectomy,
vaginoplasty, clitoroplasty, labiaplasty, breast
augmentation, facial gender affirming surgery (limited to
chondrolaryngoplasty, rhinoplasty, contouring or
augmentation of the jaw, chin, and forehead; facelift, hair
removal and transplantation, pitch raising surgery/Wendler
glottoplasty, cosmetic fillers, botulinum toxin, fat grafting
and liposuction), and electrolysis (hair removal at the
covered operative site)
Note: Prior approval is required for gender affirming
surgery. For more information about prior approval, please refer
to Section 3.
Note: Benefits are not available for repeat or revision procedures
unless they are determined to be medically necessary. Benefits
are not available for gender affirming surgery for any condition
other than gender dysphoria.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: You may request prior
approval and receive specific
benefit information in advance
for surgeries to be performed
by Non-participating
physicians when the charge for
the surgery will be $5,000 or
more. See Section 3 for more
information.
Preferred: $150 copayment per
performing surgeon, for
surgical procedures performed
in an office setting
Preferred: $200 copayment per
performing surgeon, for
surgical procedures performed
in all other settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact
the provider if you have any
questions about the place of
service.
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered
or obtained in connection with
your care.
Participating/Non-
participating: You pay all
charges
Reconstructive Surgery - continued on next page
64 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Reconstructive Surgery (cont.) Standard Option Basic Option
• Gender affirming surgery on an inpatient or outpatient basis is
subject to the pre-surgical requirements listed below. The
member must meet all requirements.
- Prior approval is obtained
- Member must be at least 16 years of age for mastectomy
and 18 years of age for other covered surgeries at the
time prior approval is requested and the treatment plan
is submitted
- Diagnosis of gender dysphoria by a qualified healthcare
professional with well-documented persistent gender
incongruence, including documentation that other possible
causes of gender incongruence have been excluded
- Member must meet the following criteria:
• 6 months of continuous hormone therapy appropriate to
the member’s gender identity (unless medically
contraindicated and they are not required for
mastectomy)
• Documentation of informed consent and fulfillment of
the program’s criteria for gender affirming surgical
treatment
• Must have a written psychological assessment from a
qualified mental health professional documenting the
diagnosis of persistent gender dysphoria with a well-
documented persistent gender incongruence between the
assigned gender and the experienced/expressed gender or
some alternative gender, support of surgical procedure
(s), and well-controlled physical and mental health
conditions
• Surgical treatment plan must include timing, technique,
and duration of aftercare
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: You may request prior
approval and receive specific
benefit information in advance
for surgeries to be performed
by Non-participating
physicians when the charge for
the surgery will be $5,000 or
more. See Section 3 for more
information.
Preferred: $150 copayment per
performing surgeon, for
surgical procedures performed
in an office setting
Preferred: $200 copayment per
performing surgeon, for
surgical procedures performed
in all other settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact
the provider if you have any
questions about the place of
service.
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered
or obtained in connection with
your care.
Participating/Non-
participating: You pay all
charges
Not covered:
•
Cosmetic surgery – any operative procedure or any portion of
a procedure performed primarily to improve physical
appearance through change in bodily form – unless required
for a congenital anomaly or to restore or correct a part of the
body that has been altered as a result of accidental injury,
disease, or surgery (does not include anomalies related to the
teeth or structures supporting the teeth)
•
Surgeries related to sexual dysfunction or sexual inadequacy
(except surgical placement of penile prostheses to treat
erectile dysfunction)
•
Reversal of gender affirming surgery
All chargesAll charges
65 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Oral and Maxillofacial Surgery Standard Option Basic Option
Oral surgical procedures, limited to:
• Excision of tumors and cysts of the jaws, cheeks, lips, tongue,
roof and floor of mouth when pathological examination is
necessary
• Surgery needed to correct accidental injuries to jaws, cheeks,
lips, tongue, roof and floor of mouth
Note: Prior approval is required for oral/maxillofacial
surgery needed to correct accidental injuries as described
above, except when care is provided within 72 hours of the
accidental injury. Please refer to Section 3 for more
information.
• Excision of exostoses of jaws and hard palate
• Incision and drainage of abscesses and cellulitis
• Incision and surgical treatment of accessory sinuses, salivary
glands, or ducts
• Reduction of dislocations and excision of temporomandibular
joints
• Removal of impacted teeth
Note: Dentists and oral surgeons who are in our Preferred Dental
Network for routine dental care are not necessarily Preferred
providers for other services covered by this Plan under other
benefit provisions (such as the surgical benefit for oral and
maxillofacial surgery). Call us at the customer service phone
number on the back of your ID card to verify that your provider
is Preferred for the type of care (e.g., routine dental care or oral
surgery) you are scheduled to receive.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Note: You may request prior
approval and receive specific
benefit information in advance
for surgeries to be performed
by Non-participating
physicians when the charge for
the surgery will be $5,000 or
more. See Section 3 for more
information.
Preferred: $150 copayment per
performing surgeon, for
surgical procedures performed
in an office setting
Preferred: $200 copayment per
performing surgeon, for
surgical procedures performed
in all other settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact
the provider if you have any
questions about the place of
service.
Note: If you receive the
services of a co-surgeon, you
pay a separate copayment for
those services, based on where
the surgical procedure is
performed. No additional
copayment applies to the
services of assistant surgeons.
Note: You pay 30% of the Plan
allowance for agents, drugs,
and/or supplies administered
or obtained in connection with
your care.
Participating/Non-
participating: You pay all
charges
Not covered:
•
Oral implants and transplants except for those required to
treat accidental injuries as specifically and previously
described and in Section 5(g)
•
Surgical procedures that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva, and
alveolar bone), except for those required to treat accidental
injuries as specifically and previously described and in
Section 5(g)
•
Surgical procedures involving dental implants or preparation
of the mouth for the fitting or the continued use of dentures,
except for those required to treat accidental injuries as
specifically and previously described and in Section 5(g)
•
Orthodontic care before, during, or after surgery, except for
orthodontia associated with surgery to correct accidental
injuries as specifically and previously described and in
Section 5(g)
All chargesAll charges
66 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Organ and Tissue Transplants Standard Option Basic Option
Solid organ/tissue transplants are subject to medical
necessity and experimental/investigational review. For the
solid organ transplants listed below, you must obtain prior
approval from the Local Plan for the procedures, and you
must obtain precertification for the facility. (See
precertification and prior approval in Section 3.)
• Heart transplant
• Heart-lung transplant
• Kidney transplant
• Liver transplant
• Pancreas transplant
• Combination liver-kidney transplant
• Combination pancreas-kidney transplant
• Autologous pancreas islet cell transplant (as an adjunct
to total or near total pancreatectomy) only for patients
with chronic pancreatitis
• Intestinal transplants (small intestine) and the small
intestine with the liver or small intestine with multiple
organs such as the liver, stomach, and pancreas
• Single, double, or lobar lung transplant
- Benefits for lung transplantation are limited to
double lung transplants for members with end-stage
cystic fibrosis.
• Implantation of an artificial heart as a bridge to
transplant or destination therapy
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: $150 copayment per
performing surgeon, for surgical
procedures performed in an office
setting
Preferred: $200 copayment per
performing surgeon, for surgical
procedures performed in all other
settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact the
provider if you have any
questions about the place of
service.
Note: If you receive the services
of a co-surgeon, you pay a
separate copayment for those
services, based on where the
surgical procedure is performed.
No additional copayment applies
to the services of assistant
surgeons.
Participating/Non-participating:
You pay all charges
Note: Solid Organ transplants must be performed in a facility with a Medicare-Approved Transplant Program for the type of
transplant anticipated. Transplants involving more than one organ must be performed in a facility that offers a Medicare-Approved
Transplant Program for each organ transplanted.
Note: If Medicare does not offer an approved program for a certain type of organ transplant procedure, this requirement does not
apply, and you may use any covered facility that performs the procedure.
Note: If Medicare offers an approved program for an anticipated organ transplant, but your facility is not approved by Medicare for
the procedure, please contact your Local Plan at the customer service phone number on the back of your ID card.
All the following blood or marrow stem cell transplants - Prior approval is required and must be performed in a facility with a
transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT), or in a facility designated as a
Blue Distinction Center for Transplants or as a Cancer Research Facility. See Section 3 for more information about these types of
facilities.
Not every facility provides transplant services for every type of transplant procedure or condition listed or is designated or accredited
for every covered transplant. Benefits are not provided for a covered transplant procedure unless the facility is specifically designated
or accredited to perform that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number
listed on the back of your ID card for assistance in locating an eligible facility and requesting prior approval for transplant services for
the diagnoses as indicated below:
Physicians consider many features to determine how diseases will respond to different types of treatments. Some of the features
measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and
how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to
treatment without transplant and which diseases may respond to transplant.
67 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Organ and Tissue Transplants Standard Option Basic Option
Allogeneic blood or marrow stem cell transplants
limited to the diagnoses and stages indicated below:
• Acute lymphocytic or myeloid (e.g., AML
promyelocytic) leukemia
• Blastic plasmacytoid dendritic cell neoplasm
• Chronic lymphocytic leukemia (e.g., T cell
prolymphocytic leukemia, B cell prolymphocytic
leukemia, hairy cell leukemia)
• Chronic myeloid leukemia
• Hemoglobinopathy (e.g., sickle cell anemia,
thalassemia major)
• Hodgkin lymphoma
• Inherited metabolic disorders: Adrenoleukodystrophy,
Globoid cell leukodystrophy (Krabbe's
leukodystrophy), Metachromatic leukodystrophy, and
Mucopolysaccharidosis type I (Hurler syndrome)
• IPEX - immune dysregulation, polyendocrinopathy,
enteropathy, X-linked syndrome
• Marrow failure (e.g., severe aplastic anemia, Fanconi’s
anemia, paroxysmal nocturnal hemoglobinuria (PNH),
pure red cell aplasia, congenital thrombocytopenia,
Dyskeratosis congenita)
• MDS/MPN (e.g., chronic myelomonocytic leukemia
(CMML))
• Myelodysplastic syndromes (MDS)
• Myeloproliferative neoplasms (MPN) (e.g.,
polycythemia vera, essential thrombocythemia,
primary myelofibrosis, Hypereosinophilic syndromes)
• Non-Hodgkin lymphoma (e.g., Waldenstrom’s
macroglobulinemia, B-cell lymphoma, Burkitt
lymphoma)
• Osteopetrosis
• Plasma cell disorders (e.g., multiple myeloma,
amyloidosis, plasma cell leukemia, POEMS –
(polyneuropathy, organomegaly, endocrinopathy,
monoclonal gammopathy, and skin changes syndrome)
• Primary immunodeficiencies (e.g., severe combined
immunodeficiency, Wiskott-Aldrich syndrome,
hemophagocytic disorders, X-linked
lymphoproliferative syndrome, severe congenital
neutropenia, leukocyte adhesion deficiencies, common
variable immunodeficiency, chronic granulomatous
disease/phagocytic cell disorders)
• Systemic mastocytosis, aggressive
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: $150 copayment per
performing surgeon, for surgical
procedures performed in an office
setting
Preferred: $200 copayment per
performing surgeon, for surgical
procedures performed in all other
settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact the
provider if you have any
questions about the place of
service.
Note: If you receive the services
of a co-surgeon, you pay a
separate copayment for those
services, based on where the
surgical procedure is performed.
No additional copayment applies
to the services of assistant
surgeons.
Participating/Non-participating:
You pay all charges.
Organ and Tissue Transplants - continued on next page
68 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Organ and Tissue Transplants (cont.) Standard Option Basic Option
Autologous blood or marrow stem cell transplants
limited to the diagnoses and stages indicated below:
• Acute myeloid leukemia
• Autoimmune - limited to: Idiopathic (juvenile)
rheumatoid arthritis, multiple sclerosis (treatment-
refractory relapsing with high risk of future disability)
and Scleroderma/systemic sclerosis
• Central nervous system (CNS) embryonal tumors (e.g.,
atypical teratoid/rhabdoid tumor, primitive
neuroectodermal tumors (PNETs), medulloblastoma,
pineoblastoma, ependymoblastoma)
• Chronic lymphocytic leukemia (e.g., T cell
prolymphocytic leukemia, B cell prolymphocytic
leukemia, hairy cell leukemia)
• Ewing sarcoma
• Germ cell tumors (e.g., testicular germ cell tumors)
• High-risk or relapsed neuroblastoma
• Hodgkin lymphoma
• Non-Hodgkin lymphoma (e.g., Waldenstrom’s
macroglobulinemia, B-cell lymphoma, Burkitt
lymphoma)
• Osteosarcoma
• Plasma cell disorders (e.g., multiple myeloma,
amyloidosis, plasma cell leukemia, POEMS –
(polyneuropathy, organomegaly, endocrinopathy,
monoclonal gammopathy, and skin changes syndrome)
• Wilms Tumor
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: $150 copayment per
performing surgeon, for surgical
procedures performed in an office
setting
Preferred: $200 copayment per
performing surgeon, for surgical
procedures performed in all other
settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact the
provider if you have any
questions about the place of
service.
Note: If you receive the services
of a co-surgeon, you pay a
separate copayment for those
services, based on where the
surgical procedure is performed.
No additional copayment applies
to the services of assistant
surgeons.
Participating/Non-participating:
You pay all charges
Blood or marrow stem cell transplants for the
diagnoses below, only when performed as part of a
clinical trial that meets the transplant program prior
approval criteria and the requirements listed in the
bullets below.
• Allogeneic blood or marrow stem cell transplants for:
- Autoimmune - limited to scleroderma/systemic
sclerosis, systemic lupus erythematosus, CIDP –
(chronic inflammatory demyelinating
polyneuropathy), and Idiopathic (Juvenile)
rheumatoid arthritis
- Breast cancer
- Germ Cell Tumors
- High-risk or relapsed neuroblastoma
- Lysosomal metabolic diseases: e.g.,
Mucopolysaccharidosis type II (Hunter syndrome);
Mucopolysaccharidosis type IV (Morquio
syndrome); Mucopolysaccharidosis type VI
(Maroteaux-Lamy syndrome), Fabry disease,
Gaucher disease
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: $150 copayment per
performing surgeon, for surgical
procedures performed in an office
setting
Preferred: $200 copayment per
performing surgeon, for surgical
procedures performed in all other
settings
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact the
provider if you have any
questions about the place of
service.
Organ and Tissue Transplants - continued on next page
69 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Organ and Tissue Transplants (cont.) Standard Option Basic Option
• Continued from previous page:
- Renal cell carcinoma
- Sarcoma - Ewing sarcoma, rhabdomyosarcoma, soft
tissue sarcoma
• Autologous blood or marrow stem cell transplants for:
- Autoimmune disease - e.g., systemic lupus
erythematosus, CIDP (chronic inflammatory
demyelinating polyneuropathy), Crohn's disease,
Polymyositis-dermatomyositis, rheumatoid arthritis
- Glial tumors (e.g., anaplastic astrocytoma, choroid
plexus tumors, ependymoma, glioblastoma
multiforme)
- Sarcoma (e.g., rhabdomyosarcoma, soft tissue
sarcoma)
See previous page Continued from previous page:
Note: If you receive the services
of a co-surgeon, you pay a
separate copayment for those
services, based on where the
surgical procedure is performed.
No additional copayment applies
to the services of assistant
surgeons.
Participating/Non-participating:
You pay all charges
•Requirements for blood or marrow stem cell transplants covered only under clinical trials:
- You must contact us at the customer service phone number listed on the back of your ID card to obtain prior approval (see
Section 3); and
- The patient must be properly and lawfully registered in the clinical trial, meeting all the eligibility requirements of the trial; and
- The clinical trial must be reviewed and approved by the Institutional Review Board IRB of the FACT-accredited facility, Blue
Distinction Center for Transplants, or Cancer Research Facility where the procedure is to be performed.
Note: Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries
to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. A clinical trial has possible benefits as
well as risks. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in
the trial, and the beginning and end points of the trial. Information regarding clinical trials is available at http://www.cancer.gov/
about-cancer/treatment/clinical-trials. If a non-randomized clinical trial for a blood or marrow stem cell transplant listed above
meeting the requirements shown above is not available, we will arrange for the transplant to be provided at an approved transplant
facility, if available.
Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials
or there may not be any trials available in a FACT-accredited facility, Blue Distinction Center for Transplants, or Cancer Research
Facility to treat your condition at the time you seek to be included in a clinical trial. If your physician has recommended you
participate in a clinical trial, we encourage you to contact the Case Management Department at your Local Plan for assistance. Note:
See Section 9 for our coverage of other costs associated with clinical trials.
Benefit Description You Pay
Organ and Tissue Transplants Standard Option Basic Option
Related transplant services:
• Extraction or reinfusion of blood or marrow stem cells
as part of a covered allogeneic or autologous transplant
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the
Plan allowance (deductible
applies), plus any difference
between our allowance and the
billed amount
Preferred: $150 copayment per
performing surgeon, for surgical
procedures performed in an office
setting
Preferred: $200 copayment per
performing surgeon, for surgical
procedures performed in all other
settings
Organ and Tissue Transplants - continued on next page
70 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Organ and Tissue Transplants (cont.) Standard Option Basic Option
• Harvesting, immediate preservation, and storage of
stem cells when the autologous blood or marrow stem
cell transplant has been scheduled or is anticipated to
be scheduled within an appropriate time frame for
patients diagnosed at the time of harvesting with one of
the conditions listed in this section
Note: Benefits are available for charges related to fees
for storage of harvested autologous blood or marrow
stem cells related to a covered autologous stem cell
transplant that has been scheduled or is anticipated to
be scheduled within an appropriate time frame. No
benefits are available for any charges related to fees for
long term storage of stem cells.
• Collection, processing, storage, and distribution of cord
blood only when provided as part of a blood or marrow
stem cell transplant scheduled or anticipated to be
scheduled within an appropriate time frame for patients
diagnosed with one of the conditions listed in this
section
• Covered medical and hospital expenses of the donor,
when we cover the recipient
• Covered services or supplies provided to the recipient
• Donor screening tests for non-full sibling (such as
unrelated) potential donors, for any full sibling
potential donors, and for the actual donor used for
transplant
Note: See Section 5(a) for coverage for related services,
such as chemotherapy and/or radiation therapy and drugs
administered to stimulate or mobilize stem cells for
covered transplant procedures.
See previous page Continued from previous page:
Note: Your provider will
document the place of service
when filing your claim for the
procedure(s). Please contact the
provider if you have any
questions about the place of
service.
Note: If you receive the services
of a co-surgeon, you pay a
separate copayment for those
services, based on where the
surgical procedure is performed.
No additional copayment applies
to the services of assistant
surgeons.
Participating/Non-participating:
You pay all charges
Organ/Tissue Transplants at Blue Distinction Centers for Transplants
®
We participate in the Blue Distinction Centers for Transplants Program for the organ/tissue transplants listed below.
Members who choose to use a Blue Distinction Center for Transplants for a covered transplant only pay the $350 per admission
copayment under Standard Option, or the $250 per day copayment ($1,500 maximum) under Basic Option, for the transplant period.
See Section 10 for the definition of “transplant period.” Members are not responsible for additional costs for included professional
services.
Regular benefits (subject to the regular cost-sharing levels for facility and professional services) are paid for pre- and post-transplant
services performed in Blue Distinction Centers for Transplants before and after the transplant period and for services unrelated to a
covered transplant.
All members (including those who have Medicare Part A or another group health insurance policy as their primary payor)
must contact us at the customer service phone number listed on the back of their ID card before obtaining services. You will be
referred to the designated Plan transplant coordinator for information about Blue Distinction Centers for Transplants.
•Heart (adult and pediatric)
•Kidney (adult and pediatric)
•Liver (adult and pediatric liver alone; adult only for combination liver-kidney)
•Single or double lung (adult only)
71 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
•Blood or marrow stem cell transplants (adult and pediatric) listed in this section
•Related transplant services previously listed
Travel benefits:
Members who receive covered care at a Blue Distinction Center for Transplants for one of the transplants listed above can be
reimbursed for incurred travel costs related to the transplant, subject to the criteria and limitations described here.
We reimburse costs for transportation (air, rail, bus, and/or taxi) and lodging if you live 50 miles or more from the facility, up to a
maximum of $5,000 per transplant for the member and companions. If the transplant recipient is age 21 or younger, we pay up to
$10,000 for eligible travel costs for the member and companions. Reimbursement is subject to IRS regulations.
Note: You must obtain prior approval for travel benefits (see Section 3).
Note: Benefits for intestinal, pancreas, pediatric lung, and heart-lung transplants are not available through Blue Distinction Centers for
Transplants.
Note: See Section 5(c) for our benefits for facility care.
Benefit Description You Pay
Organ/Tissue Transplants Standard
Option
Basic
Option
Not covered:
•
Any transplant not listed as covered and transplants for any diagnosis not listed as covered
•
Donor screening tests and donor search expenses, including associated travel expenses, except as
previously defined
•
Implants of artificial organs, including those implanted as a bridge to transplant and/or as destination
therapy, other than medically necessary implantation of an artificial heart as previously described
•
Allogeneic pancreas islet cell transplantation
•
Travel costs related to covered transplants performed at facilities other than Blue Distinction Centers
for Transplants; travel costs incurred when prior approval has not been obtained; travel costs outside
those allowed by IRS regulations, such as food-related expenses
All
charges
All
charges
Benefit Description You Pay
Anesthesia Standard Option Basic Option
Anesthesia (including acupuncture) for covered medical or
surgical services when requested by the attending physician and
performed by:
• A certified registered nurse anesthetist (CRNA), or
• A physician other than the physician (or the assistant)
performing the covered medical or surgical procedure
Professional services provided in:
• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Residential treatment center
• Office
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the Plan
allowance (deductible applies), plus
any difference between our
allowance and the billed amount
Preferred: Nothing
Participating/Non-
participating: You pay all
charges
Anesthesia - continued on next page
72 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Standard and Basic Option
Benefit Description You Pay
Anesthesia (cont.) Standard Option Basic Option
Anesthesia services consist of administration by injection or
inhalation of a drug or other anesthetic agent (including
acupuncture) to obtain muscular relaxation, loss of sensation, or
loss of consciousness.
Note: Anesthesia acupuncture services do not accumulate
toward the member’s annual maximum.
Note: See Section 5(c) for our payment levels for anesthesia
services billed by a facility.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the Plan
allowance (deductible applies), plus
any difference between our
allowance and the billed amount
Preferred: Nothing
Participating/Non-
participating: You pay all
charges
Not covered:
•
Anesthesia related to noncovered surgeries or procedures
All chargesAll charges
73 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(b)
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance
Services
Standard and Basic Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
•Be sure to read Section 4,
Your Costs for Covered Services
, for valuable information about how cost-sharing
works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age
65 or over.
•YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL
RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3 to be sure
which services require precertification.
•Note: Observation services are billed as outpatient facility care. Benefits for observation services are
provided at the outpatient facility benefit levels described in this section. See Section 10,
Definitions
, for
more information about these types of services.
•YOU MUST GET PRIOR APPROVAL for the following services: facility-based sleep studies; surgery
for severe obesity; and surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof
and floor of mouth, except when care is provided within 72 hours of the accidental injury. Please refer
to Section 3 for more information.
•YOU MUST GET PRIOR APPROVAL for gender affirming surgery. See Section 3 for prior approval
and Section 5(b) for the surgical benefit.
•You should be aware that some Non-preferred (non-PPO) professional providers may provide services in
Preferred (PPO) facilities.
•We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will
find that some benefits are listed in more than one Section of the brochure. This is because how they are paid
depends on what type of provider or facility bills for the service.
•The services listed in this Section are for the charges billed by the facility (i.e., hospital or surgical center) or
ambulance service, for your inpatient or outpatient surgery or care. Any costs associated with the professional
charge (i.e., physicians, etc.) are listed in Sections 5(a) or 5(b).
•PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO
benefits apply.
•Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drug
when obtained from a covered provider other than a pharmacy under the pharmacy benefit. This benefit
limitation does not apply if you have primary Medicare Part B coverage or are enrolled in the FEP Medicare
Prescription Drug Program. See Section 5(f) for information about Tier 4 and Tier 5 specialty drug fills from
Preferred providers and Preferred pharmacies. Medications restricted under this benefit are available on our
Specialty Drug List. Visit www.fepblue.org/specialtypharmacy or call us at 888-346-3731.
•Under Standard Option,
- The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment).
•Under Basic Option,
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits. See Section 3 for the exceptions to this
requirement.
- Your cost-share for care performed and billed by Preferred professional providers in the outpatient
department of a Preferred hospital is waived for services other than surgical services, drugs, supplies,
orthopedic and prosthetic devices, and durable medical equipment. You are responsible for the applicable
cost-sharing amount(s) for the services performed and billed by the hospital.
74 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section.
There is no calendar year deductible under Basic Option.
Inpatient Hospital Standard Option Basic Option
Room and board, such as:
• Semiprivate or intensive care accommodations
• General nursing care
• Meals and special diets
Note: We cover a private room only when you must be
isolated to prevent contagion, when your isolation is
required by law, or when a Preferred or Member hospital
only has private rooms. If a Preferred or Member hospital
only has private rooms, we base our payment on the
contractual status of the facility. If a Non-member
hospital only has private rooms, we base our payment on
the Plan allowance for your type of admission. Please see
Section 10,
Definitions
, for more information.
See later in this section and Section 5(e) for inpatient
residential treatment center.
Other hospital services and supplies, such as:
• Operating, recovery, maternity, and other treatment
rooms
• Prescribed drugs and medications
• Diagnostic studies, radiology services, laboratory tests,
and pathology services
• Administration of blood or blood plasma
• Dressings, splints, casts, and sterile tray services
• Internal prosthetic devices
• Other medical supplies and equipment, including
oxygen
• Anesthetics and anesthesia services
• Take-home items
• Pre-admission testing recognized as part of the hospital
admissions process
• Nutritional counseling
• Acute inpatient rehabilitation
Note: Observation services are billed as outpatient
facility care. As a result, benefits for observation services
are provided at the outpatient facility benefit levels
described on in this section. See Section 10,
Definitions
,
for more information about these types of services.
Note: Here are some things to keep in mind:
• You do not need to precertify your delivery; see
Section 3 for other circumstances, such as extended
stays for you or your newborn.
Preferred facilities: $350 per
admission copayment for
unlimited days (no deductible)
Note: For facility care related to
maternity, including care at
birthing facilities, we waive the
per admission copayment and pay
for covered services in full when
you use a Preferred facility.
Member facilities: $450 per
admission copayment for
unlimited days, plus 35% of the
Plan allowance (no deductible)
Non-member facilities: $450 per
admission copayment for
unlimited days, plus 35% of the
Plan allowance (no deductible),
and any remaining balance after
our payment
Note: If you are admitted to a
Member or Non-member facility
due to a medical emergency or
accidental injury, you pay a
$350 per admission copayment
for unlimited days and we then
provide benefits at 100% of the
Plan allowance.
Preferred facilities: $250 per day
copayment up to $1,500 per
admission for unlimited days
Note: Your responsibility for
maternity care in a Preferred
facility, or birthing center, is
limited to a $250 copayment
associated with the charges
incurred during delivery.
Member/Non-member facilities:
You pay all charges
Inpatient Hospital - continued on next page
75 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Inpatient Hospital (cont.) Standard Option Basic Option
• If you need to stay longer in the hospital than initially
planned, we will cover an extended stay if it is
medically necessary. However, you must precertify the
extended stay. See Section 3 for information on
requesting additional days.
• We pay inpatient hospital benefits for an admission in
connection with the treatment of children up to age 22
with severe dental caries. We cover hospitalization for
other types of dental procedures only when a non-
dental physical impairment exists that makes
hospitalization necessary to safeguard the health of the
patient. We provide benefits for dental procedures as
shown in Section 5(g).
Note: See Section 5(a) for other covered maternity
services.
Note: See Section 5(a) for coverage of blood and blood
products.
Note: For certain surgical procedures, your out-of-pocket
costs for facility services are reduced if you use a facility
designated as a Blue Distinction Center. Keep reading
this section for more information.
Preferred facilities: $350 per
admission copayment for
unlimited days (no deductible)
Note: For facility care related to
maternity, including care at
birthing facilities, we waive the
per admission copayment and pay
for covered services in full when
you use a Preferred facility.
Member facilities: $450 per
admission copayment for
unlimited days, plus 35% of the
Plan allowance (no deductible)
Non-member facilities: $450 per
admission copayment for
unlimited days, plus 35% of the
Plan allowance (no deductible),
and any remaining balance after
our payment
Note: If you are admitted to a
Member or Non-member facility
due to a medical emergency or
accidental injury, you pay a
$350 per admission copayment
for unlimited days and we then
provide benefits at 100% of the
Plan allowance.
Preferred facilities: $250 per day
copayment up to $1,500 per
admission for unlimited days
Note: Your responsibility for
maternity care in a Preferred
facility, or birthing center, is
limited to a $250 copayment
associated with the charges
incurred during delivery.
Member/Non-member facilities:
You pay all charges
Not covered:
•
Admission to noncovered facilities, such as nursing
homes, extended care facilities, schools, or residential
treatment centers (except as described later in this
section and Section 5(e))
•
Personal comfort items, such as guest meals and beds,
phone, television, beauty and barber services
•
Private duty nursing
•
Facility room and board expenses when, in our
judgment, an admission or portion of an admission is:
-
Custodial or long-term care (see
Definitions
)
-
Convalescent care or a rest cure
-
Domiciliary care provided because care in the home
is not available or is unsuitable
• Care that is not medically necessary, such as:
- When services did not require the acute hospital
inpatient (overnight) setting but could have been
provided safely and adequately in a physician’s
office, the outpatient department of a hospital, or
some other setting, without adversely affecting your
condition or the quality of medical care you receive.
All chargesAll charges
Inpatient Hospital - continued on next page
76 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Inpatient Hospital (cont.) Standard Option Basic Option
- Admissions for, or consisting primarily of,
observation and/or evaluation that could have been
provided safely and adequately in some other setting
(such as a physician’s office)
- Admissions primarily for diagnostic studies,
radiology services, laboratory tests, or pathology
services that could have been provided safely and
adequately in some other setting (such as the
outpatient department of a hospital or a physician’s
office)
Note: If we determine that an inpatient admission is one
of the types listed above, we will not provide benefits for
inpatient room and board or inpatient physician care.
However, we will provide benefits for covered services or
supplies other than room and board and inpatient
physician care at the level that we would have paid if they
had been provided in some other setting. Benefits are
limited to care provided by covered facility providers (see
Section 3).
All chargesAll charges
Outpatient Hospital or Ambulatory Surgical
Center
Standard Option Basic Option
Outpatient surgical and treatment services performed
and billed by a facility, such as:
• Operating, recovery, and other treatment rooms
• Anesthetics and anesthesia services
• Acupuncture
• Pre-surgical testing performed within one business day
of the covered surgical services
• Chemotherapy and radiation therapy
• Colonoscopy, with or without biopsy
Note: Preventive care benefits apply to the facility
charges for your first covered colonoscopy of the
calendar year, see
Preventive Care, Adult
, in Section 5
(a). We provide diagnostic benefits for services related
to subsequent colonoscopy procedures in the same
year.
• Intravenous (IV)/infusion therapy
• Renal dialysis
• Visits to the outpatient department of a hospital for
non-emergency treatment services
• Diabetic education
• Administration of blood, blood plasma, and other
biologicals
• Blood and blood plasma, if not donated or replaced,
and other biologicals
• Dressings, splints, casts, and sterile tray services
• Facility supplies for hemophilia home care
Preferred facilities: 15% of the
Plan allowance (deductible
applies)
Member facilities: 35% of the
Plan allowance (deductible
applies)
Non-member facilities: 35% of
the Plan allowance (deductible
applies). You may also be
responsible for any difference
between our allowance and the
billed amount.
Preferred facilities: $150
copayment per day per facility
(except as noted below)
Note: You may be responsible for
paying a $200 copayment per day
per facility if other diagnostic
services are billed in addition to
the services listed here.
Note: You pay 30% of the Plan
allowance for surgical implants,
agents, or drugs administered or
obtained in connection with your
care.
Member/Non-member facilities:
You pay all charges
Outpatient Hospital or Ambulatory Surgical Center - continued on next page
77 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Outpatient Hospital or Ambulatory Surgical
Center (cont.)
Standard Option Basic Option
• Other medical supplies, including oxygen
• Surgical implants
Notes:
• See Section 5(d) for our payment levels for care related
to a medical emergency or accidental injury.
• See Section 5(a) for our coverage of family planning
services.
• For our coverage of hospital-based clinic visits, please
refer to the professional benefits described in Section 5
(a).
• For certain surgical procedures, your out-of-pocket
costs for facility services are reduced if you use a
facility designated as a Blue Distinction Center as
described later in this section.
• For outpatient facility care related to maternity,
including outpatient care at birthing facilities, we
waive your cost-share amount and pay for covered
services in full when you use a Preferred facility.
See Section 5(a) for other included maternity services.
• See later in this section for outpatient drugs, medical
devices, and durable medical equipment billed for by a
facility.
• We cover outpatient hospital services and supplies
related to the treatment of children up to age 22 with
severe dental caries.
We cover outpatient care related to other types of dental
procedures only when a non-dental physical impairment
exists that makes the hospital setting necessary to
safeguard the health of the patient. See Section 5
(g),
Dental Benefits
, for additional benefit information.
Preferred facilities: 15% of the
Plan allowance (deductible
applies)
Member facilities: 35% of the
Plan allowance (deductible
applies)
Non-member facilities: 35% of
the Plan allowance (deductible
applies). You may also be
responsible for any difference
between our allowance and the
billed amount.
Preferred facilities: $150
copayment per day per facility
(except as noted below)
Note: You may be responsible for
paying a $200 copayment per day
per facility if other diagnostic
services are billed in addition to
the services listed here.
Note: You pay 30% of the Plan
allowance for surgical implants,
agents, or drugs administered or
obtained in connection with your
care.
Member/Non-member facilities:
You pay all charges
Outpatient observation services performed and billed by
a hospital or freestanding ambulatory facility
Note: All outpatient services billed by the facility during
the time you are receiving observation services are
included in the cost-share amounts shown here. Please
refer to Section 5(a) for services billed by professional
providers during an observation stay and later in this
section for information about benefits for inpatient
admissions.
Note: For outpatient observation services related to
maternity, we waive your cost-share amount and pay for
covered services in full when you use a Preferred facility.
Preferred facilities: $350
copayment for the duration of
services (no deductible)
Member facilities: $450
copayment for the duration of
services, plus 35% of the Plan
allowance (no deductible)
Non-member facilities: $450
copayment for the duration of
services, plus 35% of the Plan
allowance (no deductible), and
any remaining balance after our
payment
Preferred facilities: $250 per day
copayment up to $1,500
Member/Non-member facilities:
You pay all charges
Outpatient Hospital or Ambulatory Surgical Center - continued on next page
78 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Outpatient Hospital or Ambulatory Surgical
Center (cont.)
Standard Option Basic Option
Outpatient diagnostic testing and treatment services
performed and billed by a facility, limited to:
• Angiographies
• Bone density tests
• CT scans/MRIs/PET scans
• Nuclear medicine
• Facility-based sleep studies (prior approval is required)
• Genetic testing (prior approval is required)
Preferred facilities: 15% of the
Plan allowance (deductible
applies)
Member facilities: 35% of the
Plan allowance (deductible
applies)
Non-member facilities: 35% of
the Plan allowance (deductible
applies). You may also be
responsible for any difference
between our allowance and the
billed amount.
Preferred facilities: $200
copayment per day per facility
Member facilities: $200
copayment per day per facility
Non-member facilities: $200
copayment per day per facility,
plus any difference between our
allowance and the billed amount
Note: You pay 30% of the Plan
allowance for agents or drugs
administered or obtained in
connection with your care.
Outpatient diagnostic testing services performed and
billed by a facility, such as:
• Cardiovascular monitoring
• EEGs
• Home-based/unattended sleep studies
• Ultrasounds
• Neurological testing
• X-rays (including set-up of portable X-ray equipment)
Note: For outpatient facility care related to maternity,
including outpatient care at birthing facilities, we waive
your cost-share amount and pay for covered services in
full when you use a Preferred facility.
Preferred facilities: 15% of the
Plan allowance (deductible
applies)
Member facilities: 35% of the
Plan allowance (deductible
applies)
Non-member facilities: 35% of
the Plan allowance (deductible
applies). You may also be
responsible for any difference
between our allowance and the
billed amount.
Preferred facilities: $40
copayment per day per facility
Member facilities: $40 copayment
per day per facility
Non-member facilities: $40
copayment per day per facility,
plus any difference between our
allowance and the billed amount
Note: You may be responsible for
paying a higher copayment per
day per facility if other diagnostic
and/or treatment services are
billed in addition to the services
listed here.
Note: You pay 30% of the Plan
allowance for agents or drugs
administered or obtained in
connection with your care.
Outpatient treatment and therapy services performed
and billed by a facility, limited to:
• Cognitive rehabilitation therapy
• Physical, occupational, and speech therapy
- Standard Option benefits are limited to a combined
total of 75 visits per person per calendar year
- Basic Option benefits are limited to a combined total
of 50 visits per person per calendar year
• Manipulative treatment services
- Standard Option benefits are limited to a combined
total of 12 visits per person per calendar year
- Basic Option benefits are limited to a combined total
of 20 visits per person per calendar year
Preferred facilities: $30
copayment per day per facility (no
deductible)
Member facilities: 35% of the
Plan allowance (deductible
applies)
Non-member facilities: 35% of
the Plan allowance (deductible
applies). You may also be
responsible for any difference
between our allowance and the
billed amount.
Preferred facilities: $35
copayment per day per facility
Member/Non-member facilities:
You pay all charges
Note: You pay 30% of the Plan
allowance for agents or drugs
administered or obtained in
connection with your care.
Outpatient Hospital or Ambulatory Surgical Center - continued on next page
79 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Outpatient Hospital or Ambulatory Surgical
Center (cont.)
Standard Option Basic Option
Outpatient treatment services performed and billed by a
facility, limited to:
• Cardiac rehabilitation
• Pulmonary rehabilitation
• Applied behavior analysis (ABA) for an autism
spectrum disorder (see prior approval requirements in
Section 3)
Preferred facilities: 15% of the
Plan allowance (deductible
applies)
Member facilities: 35% of the
Plan allowance (deductible
applies)
Non-member facilities: 35% of
the Plan allowance (deductible
applies). You may also be
responsible for any difference
between our allowance and the
billed amount.
Preferred facilities: $35
copayment per day per facility
Note: You may be responsible for
paying a higher copayment per
day per facility if other diagnostic
and/or treatment services are
billed in addition to the services
listed here.
Note: You pay 30% of the Plan
allowance for agents or drugs
administered or obtained in
connection with your care.
Member/Non-member facilities:
You pay all charges
Outpatient diagnostic and treatment services performed
and billed by a facility, limited to:
• Laboratory tests and pathology services
• EKGs
Note: For outpatient facility care related to maternity,
including outpatient care at birthing facilities, we waive
your cost-share amount and pay for covered services in
full when you use a Preferred facility.
Preferred facilities: 15% of the
Plan allowance (deductible
applies)
Member facilities: 35% of the
Plan allowance (deductible
applies)
Non-member facilities: 35% of
the Plan allowance (deductible
applies). You may also be
responsible for any difference
between our allowance and the
billed amount.
Preferred facilities: 15% of the
Plan allowance
Member facilities: 15% of the
Plan allowance
Non-member facilities: 15% of
the Plan allowance plus any
difference between our allowance
and the billed amount
Note: You may be responsible for
paying a copayment per day per
facility if other diagnostic and/or
treatment services are billed in
addition to the services listed
here.
Note: You pay 30% of the Plan
allowance for agents or drugs
administered or obtained in
connection with your care.
Outpatient adult preventive care performed and billed
by a facility, limited to:
• Visits/exams for preventive care, screening procedures,
and routine immunizations described in Section 5(a)
• Cancer screenings listed in Section 5(a) and ultrasound
screening for abdominal aortic aneurysm
Note: See Section 5(a) for our payment levels for covered
preventive care services for children billed for by
facilities and performed on an outpatient basis.
See Section 5(a) for our payment
levels for covered preventive care
services for adults
Preferred facilities: Nothing
Member/Non-member facilities:
Nothing for cancer screenings and
ultrasound screening for
abdominal aortic aneurysm
Note: Benefits are not available
for routine adult physical
examinations, associated
laboratory tests, colonoscopies, or
routine immunizations performed
at Member or Non-member
facilities.
Outpatient Hospital or Ambulatory Surgical Center - continued on next page
80 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Outpatient Hospital or Ambulatory Surgical
Center (cont.)
Standard Option Basic Option
Outpatient drugs, medical devices, and durable
medical equipment billed for by a facility, such as:
• Prescribed drugs
• Orthopedic and prosthetic devices
• Durable medical equipment
• Surgical implants
Note: For outpatient facility care related to maternity,
including outpatient care at birthing facilities, we waive
your cost-share amount and pay for covered services in
full when you use a Preferred facility.
Note: Certain self-injectable drugs are covered only when
dispensed by a pharmacy under the pharmacy benefit.
These drugs will be covered once per lifetime per
therapeutic category of drugs when dispensed by a non-
pharmacy-benefit provider. This benefit limitation does
not apply if you have primary Medicare Part B coverage,
or are enrolled in the Medicare Prescription Drug
Program.
Preferred facilities: 15% of the
Plan allowance (deductible
applies)
Member facilities: 35% of the
Plan allowance (deductible
applies)
Non-member facilities: 35% of
the Plan allowance (deductible
applies). You may also be
responsible for any difference
between our allowance and the
billed amount.
Preferred facilities: 30% of the
Plan allowance
Note: You may also be
responsible for paying a
copayment per day per facility for
other outpatient services listed in
this section.
Member/Non-member facilities:
You pay all charges
Blue Distinction® Specialty Care Standard Option Basic Option
We provide enhanced benefits for covered inpatient
facility services related to the surgical procedures listed
below, when the surgery is performed at a facility
designated as a Blue Distinction Center for Knee and Hip
Replacement, Blue Distinction Center for Spine Surgery,
or Blue Distinction Center for Comprehensive Bariatric
Surgery.
• Bariatric surgeries covered are:
- Roux-en-Y gastric bypass
- Laparoscopic adjustable gastric banding
- Sleeve gastrectomy
- Biliopancreatic bypass with duodenal switch
• Total hip replacement or revision
• Total knee replacement or revision
• Spine surgery, limited to:
- Cervical discectomy
- Thoracic discectomy
- Laminectomy
- Laminoplasty
- Spinal fusion
Note: You must precertify your hospital stay and verify
your facility’s designation as a Blue Distinction Center
for the type of surgery being scheduled. Contact us prior
to your admission at the customer service phone number
listed on the back of your ID card for assistance.
Blue Distinction Center: $150 per
admission copayment for
unlimited days (no deductible)
Blue Distinction Center: $100 per
day copayment up to $500 per
admission for unlimited days
Blue Distinction® Specialty Care - continued on next page
81 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Blue Distinction® Specialty Care (cont.) Standard Option Basic Option
Note: Members are responsible for regular cost-sharing
amounts for the surgery and related professional services
as described in Section 5(b).
Note: These benefit levels do not apply to inpatient
facility care related to other services or procedures, or to
outpatient facility care, even if the services are performed
at a Blue Distinction Center.
Note: See Section 3 for more information about Blue
Distinction Centers.
Blue Distinction Center: $150 per
admission copayment for
unlimited days (no deductible)
Blue Distinction Center: $100 per
day copayment up to $500 per
admission for unlimited days
Outpatient facility services related to specific covered
bariatric surgical procedures, when the surgery is
performed at a designated Blue Distinction Center for
Bariatric Surgery.
Outpatient facility services related to specific covered hip
and knee replacement or revision surgeries and certain
spine surgery procedures, when performed at a designated
Blue Distinction Center for hip/knee/spine surgery.
Note: You must meet the pre-surgical requirements listed
in our medical policies for bariatric surgeries.
Note: In addition, you must obtain prior approval and
verify the facility’s designation as a Blue Distinction
Center for the type of surgery being scheduled. Contact
us prior to the procedure at the customer service phone
number listed on the back of your ID card for assistance.
Note: Members are responsible for regular cost-sharing
amounts for the surgery and related professional services
as described in Section 5(b).
Note: These benefits do not apply to other types of
outpatient surgical services, even when performed at a
Blue Distinction Center.
Note: See Section 3 for more information about Blue
Distinction Centers.
Blue Distinction Center: $100 per
day per facility (no deductible)
Blue Distinction Center: $25 per
day per facility
Residential Treatment Center Standard Option Basic Option
Precertification prior to admission is required.
We cover inpatient care provided and billed by an RTC
when the care is medically necessary for the treatment of
a medical, mental health, and/or substance use disorder:
• Room and board, such as semiprivate room, nursing
care, meals, special diets, ancillary charges, and
covered therapy services when billed by the facility.
Note: RTC benefits are not available for facilities licensed
as a skilled nursing facility, group home, halfway house,
or similar type facility.
Preferred facilities: $350 per
admission copayment for
unlimited days (no deductible)
Member facilities: $450 per
admission copayment for
unlimited days, plus 35% of the
Plan allowance (no deductible)
Non-member facilities: 35% of
the Plan allowance (no
deductible), and any remaining
balance after our payment
Preferred facilities: $250 per day
copayment up to $1,500 per
admission for unlimited days
Member/Non-member facilities:
You pay all charges
Residential Treatment Center - continued on next page
82 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Residential Treatment Center (cont.) Standard Option Basic Option
Note: Benefits are not available for noncovered services,
including: respite care; outdoor residential programs;
services provided outside of the provider’s scope of
licensure; recreational therapy; educational therapy;
educational classes; biofeedback; Outward Bound
programs; equine/hippotherapy provided during the
approved stay; personal comfort items, such as guest
meals and beds, phone, television, beauty and barber
services; custodial or long-term care (see Definitions);
and domiciliary care provided because care in the home is
not available or is unsuitable.
Note: For outpatient residential treatment center services,
see Section 5(e).
Preferred facilities: $350 per
admission copayment for
unlimited days (no deductible)
Member facilities: $450 per
admission copayment for
unlimited days, plus 35% of the
Plan allowance (no deductible)
Non-member facilities: 35% of
the Plan allowance (no
deductible), and any remaining
balance after our payment
Preferred facilities: $250 per day
copayment up to $1,500 per
admission for unlimited days
Member/Non-member facilities:
You pay all charges
Extended Care Benefits/Skilled Nursing Care
Facility Benefits
Standard Option Basic Option
When Medicare Part A is not your primary payor:
For members who do not have Medicare Part A, we cover
skilled nursing facility (SNF) inpatient care for a
maximum of 30 days annually, when the member can be
expected to benefit from short-term SNF services with a
goal of returning home.
Note: Precertification is required prior to admission
(including overseas care).
Benefits are not available for inpatient SNF care solely
for management of tube feedings, for home level dialysis
treatment, as an interim transition to long-term care
placement, or for any other noncovered services.
Note: Inpatient benefits (such as room and board) may
not be provided if precertification is not obtained prior to
admission (see Section 3).
Preferred facilities: $175 (no
deductible) per admission
Member facilities: $275 plus 35%
of the Plan allowance (no
deductible) per admission
Non-member facilities: $275 plus
35% of the Plan allowance (no
deductible), and any remaining
balance after our payment, per
admission
All charges
When Medicare Part A is your primary payor:
When Medicare Part A is the primary payor (meaning it
pays first) and has made a payment, Standard Option
provides limited secondary benefits.
We pay the applicable Medicare Part A copayments
incurred in full during the first through the 30th day of
confinement for each benefit period (as defined by
Medicare) in a qualified skilled nursing facility.
Note: See https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/ge101c03.pdf
for complete Medicare benefit period definition.
If Medicare pays the first 20 days in full, Plan benefits
will begin on the 21st day (when Medicare Part A
copayments begin) and will end on the 30th day.
Preferred facilities: Nothing (no
deductible)
Member facilities: Nothing (no
deductible)
Non-member facilities: Nothing
(no deductible)
Note: You pay all charges not paid
by Medicare after the 30th day.
All charges
Extended Care Benefits/Skilled Nursing Care Facility Benefits - continued on next page
83 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Extended Care Benefits/Skilled Nursing Care
Facility Benefits (cont.)
Standard Option Basic Option
Note: See earlier in this section for benefits provided for
outpatient physical, occupational, speech, and cognitive
rehabilitation therapy, and manipulative treatment
services when billed by a skilled nursing facility. See
Section 5(f) for benefits for prescription drugs.
Note: If Medicare Part A is your primary payor, we
will only provide benefits if Medicare provided
benefits for the admission.
Preferred facilities: Nothing (no
deductible)
Member facilities: Nothing (no
deductible)
Non-member facilities: Nothing
(no deductible)
Note: You pay all charges not paid
by Medicare after the 30th day.
All charges
Not covered:
Phone, television, personal comfort items, such as guest
meals and beds, beauty and barber services, recreational
outings/trips, stretcher or wheelchair transportation, non-
emergent ambulance transport that is requested, beyond
the nearest facility adequately equipped to treat the
member’s condition, by patient or physician for
continuity of care or other reason, custodial or long term-
care (see
Definitions
), and domiciliary care provided
because care in the home is not available or is unsuitable
All chargesAll charges
Hospice Care Standard Option Basic Option
Hospice care is an integrated set of services and supplies
designed to provide palliative and supportive care to
members with a projected life expectancy of six months
or less due to a terminal medical condition, as certified by
the member’s primary care provider or specialist.
See the following See the following
Pre-Hospice Enrollment Benefits
Prior approval is not required.
Before home hospice care begins, members may be
evaluated by a physician to determine if home hospice
care is appropriate. We provide benefits for pre-
enrollment visits when provided by a physician who is
employed by the home hospice agency and when billed
by the agency employing the physician. The pre-
enrollment visit includes services such as:
• Evaluating the member’s need for pain and/or
symptom management; and
• Counseling regarding hospice and other care options
Nothing (no deductible) Nothing
Hospice Care - continued on next page
84 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Hospice Care (cont.) Standard Option Basic Option
Prior approval from the Local Plan is required for all
hospice services. Our prior approval decision will be
based on the medical necessity of the hospice treatment
plan and the clinical information provided to us by the
primary care provider (or specialist) and the hospice
provider. We may also request information from other
providers who have treated the member. All hospice
services must be billed by the approved hospice agency.
You are responsible for making sure the hospice care
provider has received prior approval from the Local
Plan (see Section 3 for instructions). Please check with
your Local Plan, and/or visit www.fepblue.org/provider to
use our National Doctor & Hospital Finder, for listings of
Preferred hospice providers.
Note: If Medicare Part A is the primary payor for the
member’s hospice care, prior approval is not required.
However, our benefits will be limited to those services
described here.
Members with a terminal medical condition (or those
acting on behalf of the member) are encouraged to
contact the Case Management Department at their
Local Plan for information about hospice services and
Preferred hospice providers.
Nothing (no deductible) Nothing
Covered services
We provide benefits for the hospice services listed below
when the services have been included in an approved
hospice treatment plan and are provided by the home
hospice program in which the member is enrolled:
• Advanced care planning (see Section 10)
• Dietary counseling
• Durable medical equipment rental
• Medical social services
• Medical supplies
• Nursing care
• Oxygen therapy
• Periodic physician visits
• Physical therapy, occupational therapy, and speech
therapy related to the terminal medical condition
• Prescription drugs and medications
• Services of home health aides (certified or licensed, if
the state requires it, and provided by the home hospice
agency)
See next page See next page
Hospice Care - continued on next page
85 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Hospice Care (cont.) Standard Option Basic Option
Traditional Home Hospice Care
Periodic visits to the member’s home for the management
of the terminal medical condition and to provide limited
patient care in the home. An episode of care is one home
hospice treatment plan per calendar year.
Preferred facilities: Nothing (no
deductible)
Member/Non-member facilities:
$450 copayment per episode (no
deductible)
Preferred facilities: Nothing
Member/Non-member facilities:
You pay all charges
Continuous Home Hospice Care
Services provided in the home to members enrolled in
home hospice during a period of crisis, such as frequent
medication adjustments to control symptoms or to
manage a significant change in the member’s condition,
requiring a minimum of 8 hours of care during each 24-
hour period by a registered nurse (R.N.) or licensed
practical nurse (L.P.N.).
Note: Members must receive prior approval from the
Local Plan for each episode of continuous home hospice
care. An episode consists of up to seven consecutive days
of continuous care. The member must be enrolled in a
home hospice program in order to receive benefits for
subsequent continuous home hospice care, and the
services must be provided by the home hospice program
in which the member is enrolled.
Preferred facilities: Nothing (no
deductible)
Member facilities: $450 per
episode copayment (no
deductible)
Non-member facilities: $450 per
episode copayment, plus 35% of
the Plan allowance (no
deductible), and any remaining
balance after our payment
Preferred facilities: Nothing
Member/Non-member facilities:
You pay all charges
Inpatient Hospice Care
Benefits are available for inpatient hospice care when
provided by a facility that is licensed as an inpatient
hospice facility and when:
• Inpatient services are necessary to control pain and/or
manage the member’s symptoms;
• Death is imminent; or
• Inpatient services are necessary to provide an interval
of relief (respite) to the caregiver
Note: Benefits are provided for up to 30 consecutive days
in a facility licensed as an inpatient hospice facility. The
member does not have to be enrolled in a home hospice
care program to be eligible for the first inpatient stay.
However, the member must be enrolled in a home hospice
care program in order to receive benefits for subsequent
inpatient stays.
Preferred facilities: Nothing (no
deductible)
Member facilities: $450 per
admission copayment, plus 35%
of the Plan allowance (no
deductible)
Non-member facilities: $450 per
admission copayment, plus 35%
of the Plan allowance (no
deductible), and any remaining
balance after our payment
Preferred facilities: Nothing
Member/Non-member facilities:
You pay all charges
Not covered:
•
Advanced care planning, except when provided as part
of a covered hospice care treatment plan
•
Homemaker services
•
Home hospice care (e.g., care given by a home health
aide) that is provided and billed for by other than the
approved home hospice agency when the same type of
care is already being provided by the home hospice
agency
All chargesAll charges
86 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Ambulance Standard Option Basic Option
Professional ambulance transport services to or from the
nearest hospital equipped to adequately treat your
condition, when medically necessary, and:
• Associated with covered hospital inpatient care
• Related to medical emergency
• Associated with covered hospice care
Note: We also cover medically necessary emergency care
provided at the scene when transport services are not
required.
$100 copayment per day for
ground ambulance transport
services (no deductible)
$150 copayment per day for air or
sea ambulance transport services
$100 copayment per day for
ground ambulance transport
services
$150 copayment per day for air or
sea ambulance transport services
Professional ambulance transport services to or from the
nearest hospital equipped to adequately treat your
condition, when medically necessary, and when related to
accidental injury
Note: We also cover medically necessary emergency care
provided at the scene when transport services are not
required.
Note: Prior approval is required for all non-emergent air
ambulance transport.
Nothing (no deductible)
Note: These benefit levels apply
only if you receive care in
connection with, and within 72
hours after, an accidental injury.
For services received after 72
hours, see above.
$100 copayment per day for
ground ambulance transport
services
$150 copayment per day for air or
sea ambulance transport services
Medically necessary emergency ground, air and sea
ambulance transport services to the nearest hospital
equipped to adequately treat your condition if you travel
outside the United States, Puerto Rico and the U.S. Virgin
Islands
Note: If you are traveling overseas and need assistance
with emergency evacuation services to the nearest facility
equipped to adequately treat your condition, please
contact the Overseas Assistance Center (provided by
GeoBlue) by calling 804-673-1678.
$100 copayment per day for
ground ambulance transport
services (no deductible)
$150 copayment per day for air or
sea ambulance transport services
$100 copayment per day for
ground ambulance transport
services
$150 copayment per day for air or
sea ambulance transport services
Not covered:
•
Wheelchair van services and gurney van services
•
Ambulance and any other modes of transportation to or
from services including but not limited to physician
appointments, dialysis, or diagnostic tests not
associated with covered inpatient hospital care
•
Ambulance transport that is requested, beyond the
nearest facility adequately equipped to treat the
member’s condition, by patient or physician for
continuity of care or other reason
•
Commercial air flights
•
Repatriation from an international location back to the
United States. See definition of repatriation in Section
10. Members traveling overseas should consider
purchasing a travel insurance policy that covers
repatriation to your home country.
All chargesAll charges
Ambulance - continued on next page
87 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Standard and Basic Option
Benefit Description You Pay
Ambulance (cont.) Standard Option Basic Option
•
Costs associated with overseas air or sea transportation
to other than the closest hospital equipped to
adequately treat your condition.
All chargesAll charges
88 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(c)
Section 5(d). Emergency Services/Accidents
Standard and Basic Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
•Be sure to read Section 4,
Your Costs for Covered Services
, for valuable information about how cost-sharing
works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age
65 or over.
•You should be aware that some Non-preferred (non-PPO) professional providers may provide services in
Preferred (PPO) facilities.
•We provide benefits at Preferred benefit levels for emergency room services performed by both PPO and
non-PPO providers when their services are related to an accidental injury or medical emergency. The Plan
allowance for these services is determined by the contracting status of the provider. If services are performed
by non-PPO professional providers in a PPO facility, you will be responsible for your cost-share for those
services. For more information, see Section 4, NSA.
•PPO benefits apply only when you use a PPO provider (except as described above). When no PPO provider
is available, non-PPO benefits apply.
•Under Standard Option,
- The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment).
•Under Basic Option,
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits, except in cases of medical emergency
or accidental injury. Refer to the guidelines appearing below for additional information.
What is an accidental injury?
An accidental injury is an injury caused by an external force or element such as a blow or fall and which requires immediate medical
attention, including animal bites and poisonings. (See Section 5(g) for dental care for accidental injury.)
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could
result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not
treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because
they are potentially life threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There
are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick
action.
Basic Option benefits for emergency care
Under Basic Option, you are encouraged to seek care from Preferred providers in cases of accidental injury or medical emergency.
However, if you need care immediately and cannot access a Preferred provider, we will provide benefits for the initial treatment
provided in the emergency room of any hospital – even if the hospital is not a Preferred facility. We will also provide benefits if you
are admitted directly to the hospital from the emergency room until your condition has been stabilized. In addition, we will provide
benefits for emergency ambulance transportation provided by Preferred or Non-preferred ambulance providers if the transport is due
to a medical emergency or accidental injury.
We provide emergency benefits when you have acute symptoms of sufficient severity – including severe pain – such that a prudent
layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in serious jeopardy to the person’s health, or with respect to a pregnant member, the health of the member and their
unborn child.
89 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(d)
Standard and Basic Option
Benefit Description You Pay
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section.
There is no calendar year deductible under Basic Option.
Accidental Injury Standard Option Basic Option
• Professional provider services in the emergency
room, hospital outpatient department, including
professional care, diagnostic studies, radiology
services, laboratory tests, and pathology services,
when billed by a professional provider
Preferred: Nothing (no deductible)
Participating: Nothing (no
deductible)
Non-participating: Nothing (no
deductible)
Preferred: Nothing
Participating: Nothing
Non-participating: Nothing
• Professional provider services in the provider's
office, including, diagnostic studies, radiology
services, laboratory tests, and pathology services,
when billed by a professional provider
Preferred: Nothing (no deductible)
Participating: Nothing (no
deductible)
Non-participating: Any difference
between our allowance and the
billed amount (no deductible)
Regular benefit levels apply to
covered services provided in this
setting. See Sections 5(a) and 5(b).
• Outpatient hospital services and supplies, including
professional provider services, diagnostic studies,
radiology services, laboratory tests, and pathology
services, when billed by the hospital
Preferred: Nothing (no deductible)
Member: Nothing (no deductible)
Non-member: Nothing (no
deductible)
Preferred emergency room: $250
copayment per day per facility
Member emergency room: $250
copayment per day per facility
Non-member emergency room:
$250 copayment per day per
facility
Note: If you are admitted directly
to the hospital from the emergency
room, you do not have to pay the
$250 emergency room copayment.
However, the $250 per day
copayment for Preferred inpatient
care still applies.
• Urgent care centers, licensed as and permitted to
provide emergency services and supplies, including
professional providers’ services, diagnostic studies,
radiology services, laboratory tests and pathology
services, when billed by the provider
Note: The urgent care center must be licensed as and
permitted to provide emergency services in order to
receive protections under the NSA. See Section 4 for
more information.
Preferred urgent care center:
Nothing (no deductible)
Participating urgent care center:
Nothing (no deductible)
Non-participating urgent care
center: Nothing (no deductible)
Preferred urgent care center: $35
copayment per visit
Participating/Non-participating
urgent care center: $35 copayment
per visit
• Urgent care centers, not licensed as or permitted to
provide emergency services and supplies, including
professional providers’ services, diagnostic studies,
radiology services, laboratory tests and pathology
services, when billed by the provider
Preferred urgent care center:
Nothing (no deductible)
Participating urgent care center:
Nothing (no deductible)
Non-participating urgent care
center: Any difference between our
allowance and the billed amount
(no deductible)
Preferred urgent care center: $35
copayment per visit
Participating/Non-participating
urgent care center: You pay all
charges
Accidental Injury - continued on next page
90 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(d)
Standard and Basic Option
Benefit Description You Pay
Accidental Injury (cont.) Standard Option Basic Option
Note: If you are treated by a non-PPO professional
provider in a PPO facility, you will only be responsible
for your cost-share and will not owe any difference
between our allowance and the billed amount. (See
Section 4.)
Note: We pay inpatient benefits if you are admitted. See
Sections 5(a), 5(b), and 5(c) for those benefits.
Note: See Section 5(g) for dental benefits for accidental
injuries.
Note: The benefits previously
described apply only if you receive
care in connection with, and within
72 hours after, an accidental injury.
For services received after 72
hours, regular benefits apply. See
Sections 5(a), 5(b), and 5(c) for the
benefits we provide.
Note: For drugs, services, supplies,
and/or durable medical equipment
billed by a provider other than a
hospital, urgent care center, or
physician, see Sections 5(a) and 5
(f) for the benefit levels that apply.
Note: All follow-up care must be
performed and billed for by
Preferred providers to be eligible
for benefits.
Not covered:
•
Oral surgery except as shown in Section 5(b)
•
Injury to the teeth while eating
•
Emergency room professional charges for shift
differentials
All chargesAll charges
Medical Emergency Standard Option Basic Option
• Professional provider services in the emergency
room, including professional care, diagnostic studies,
radiology services, laboratory tests, and pathology
services, when billed by a professional provider
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 15% of the Plan
allowance (deductible applies)
Non-participating: 15% of the Plan
allowance (deductible applies)
Preferred: Nothing
Participating: Nothing
Non-participating: Nothing
• Outpatient hospital emergency room services and
supplies, including professional provider services,
diagnostic studies, radiology services, laboratory
tests, and pathology services, when billed by the
hospital
Note: We pay inpatient benefits if you are admitted as a
result of a medical emergency. See Section 5(c).
Preferred: 15% of the Plan
allowance (deductible applies)
Member: 15% of the Plan
allowance (deductible applies)
Non-member: 15% of the Plan
allowance (deductible applies)
Preferred emergency room: $250
copayment per day per facility
Member emergency room: $250
copayment per day per facility
Non-member emergency room:
$250 copayment per day per
facility
Note: If you are admitted directly
to the hospital from the emergency
room, you do not have to pay the
$250 emergency room copayment.
However, the $250 per day
copayment for Preferred inpatient
care still applies.
Note: All follow-up care must be
performed and billed for by
Preferred providers to be eligible
for benefits.
Medical Emergency - continued on next page
91 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(d)
Standard and Basic Option
Benefit Description You Pay
Medical Emergency (cont.) Standard Option Basic Option
• Urgent care centers, licensed as and permitted to
provide emergency services and supplies, including
professional providers’ services, diagnostic studies,
radiology services, laboratory tests and pathology
services, when billed by the provider
Note: The urgent care center must be licensed as and
permitted to provide emergency services in order to
receive protections under the NSA. See Section 4 for
more information.
Note: Benefits for crutches, splints, braces, etc. when
billed by a provider other than the urgent care center
are stated in Section 5(a),
DME
.
Preferred urgent care center: $30
copayment per visit (no
deductible)
Participating urgent care center:
$30 copayment per visit (no
deductible)
Non-participating urgent care
center: $30 copayment per visit
(no deductible)
Preferred urgent care center: $35
copayment per visit
Participating/Non-participating
urgent care center: $35 copayment
per visit
• Urgent care centers, not licensed as or permitted to
provide emergency services and supplies, including
professional providers’ services, diagnostic studies,
radiology services, laboratory tests and pathology
services, when billed by the provider
Note: Benefits for crutches, splints, braces, etc. when
billed by a provider other than the urgent care center
are stated in Section 5(a),
DME
.
Preferred urgent care center: $30
copayment per visit (no
deductible)
Participating urgent care center:
35% of the Plan allowance
(deductible applies)
Non-participating urgent care
center: 35% of the Plan allowance
(deductible applies), plus any
difference between our allowance
and the billed amount
Preferred urgent care center: $35
copayment per visit
Participating/Non-participating
urgent care center: You pay all
charges
Not covered: Emergency room professional charges for
shift differentials
All chargesAll charges
Ambulance Standard Option Basic Option
See Section 5(c) for complete ambulance benefit and
coverage information.
See Section 5(c) See Section 5(c)
92 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(d)
Section 5(e). Mental Health and Substance Use Disorder Benefits
Standard and Basic Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
•If you have an acute chronic and/or complex condition, you may be eligible to receive the services of a
professional case manager to assist in assessing, planning, and facilitating individualized treatment options
and care. For more information about our Case Management process, please refer to Section 5(h). Contact us
at the phone number listed on the back of your Service Benefit Plan ID card if you have any questions or
would like to discuss your healthcare needs.
•Be sure to read Section 4,
Your Costs for Covered Services
, for valuable information about how cost-sharing
works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age
65 or over.
•Every year, we conduct an analysis of the financial requirements and treatment limitations which apply to
this Plan’s mental health and substance use disorder benefits in compliance with the federal Mental Health
Parity and Addiction Equity Act (the Act), and the Act’s implementing regulations. Based on the results of
this analysis, we may suggest changes to program benefits to OPM. More information on the Act is available
on the following Federal Government websites:
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html
https://www.dol.gov/ebsa/
www.samhsa.gov/health-financing/implementation-mental-health-parity-addiction-equity-act
•YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL
RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3.
•PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO
benefits apply.
•Under Standard Option,
- The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment).
- You may choose to receive care from In-Network (Preferred) or Out-of-Network (Non-preferred)
providers. Cost-sharing and limitations for In-Network (Preferred) and Out-of-Network (Non-preferred)
mental health and substance use disorder benefits are no greater than for similar benefits for other illnesses
and conditions.
•Under Basic Option,
- You must use Preferred providers in order to receive benefits. See Section 3 for the exceptions to this
requirement.
- There is no calendar year deductible.
•You should be aware that some Non-preferred (non-PPO) professional providers may provide services in
Preferred (PPO) facilities.
93 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(e)
Standard and Basic Option
Benefit Description You Pay
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section.
There is no calendar year deductible under Basic Option.
Professional Services Standard Option Basic Option
We cover professional services by licensed professional
mental health and substance use disorder practitioners
when acting within the scope of their license.
Your cost-sharing responsibilities
are no greater than for other
illnesses or conditions.
Your cost-sharing responsibilities
are no greater than for other
illnesses or conditions.
Services provided by licensed professional mental health
and substance use disorder practitioners when acting
within the scope of their license
• Individual psychotherapy
• Group psychotherapy
• Pharmacologic (medication) management
• Psychological testing
• Office visits
• Clinic visits
• Home visits
• Phone consultations and online medical evaluation and
management services (telemedicine)
Note: To locate a Preferred provider, visit www.fepblue.
org/provider to use our National Doctor & Hospital
Finder, or contact your Local Plan at the mental health
and substance use disorder phone number on the back of
your ID card.
Note: See Sections 5(a) and 5(f) for our coverage of
smoking and tobacco cessation treatment.
Note: See Section 5(a) for our coverage of mental health
visits to treat postpartum depression and depression
during pregnancy.
Note: We cover outpatient mental health and substance
use disorder services or supplies provided and billed by
residential treatment centers at the levels shown here.
Preferred: $30 copayment for the
visit (no deductible)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the Plan
allowance (deductible applies),
plus the difference between our
allowance and the billed amount
Preferred: $35 copayment per
visit
Participating/Non-participating:
You pay all charges
Telehealth professional services for:
• Behavioral health counseling
• Substance use disorder counseling
Note: Refer to Section 5(h),
Wellness and Other Special
Features
, for information on telehealth services and how
to access our telehealth provider network.
Note: Benefits are combined with telehealth services
listed in Section 5(a).
Note: Copayments are waived for members with
Medicare Part B primary.
Preferred Telehealth provider:
Nothing (no deductible) for the
first 2 visits per calendar year for
any covered telehealth service
$10 copayment per visit (no
deductible) after the 2
nd
visit
Participating/Non-participating:
You pay all charges
Preferred Telehealth provider:
Nothing for the first 2 visits per
calendar year for any covered
telehealth service
$15 copayment per visit after the
2
nd
visit
Participating/Non-participating:
You pay all charges
Professional Services - continued on next page
94 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(e)
Standard and Basic Option
Benefit Description You Pay
Professional Services (cont.) Standard Option Basic Option
• Inpatient professional services Preferred: Nothing (no deductible)
Participating: 35% of the Plan
allowance (no deductible)
Non-participating: 35% of the Plan
allowance (no deductible), plus the
difference between our allowance
and the billed amount
Preferred: Nothing
Participating/Non-participating:
You pay all charges
• Professional charges for facility-based intensive
outpatient treatment
• Professional charges for outpatient diagnostic tests
Preferred: 15% of the Plan
allowance (deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the Plan
allowance (deductible applies),
plus the difference between our
allowance and the billed amount
Preferred: Nothing
Participating/Non-participating:
You pay all charges
Inpatient Hospital or Other Covered Facility Standard Option Basic Option
Inpatient services provided and billed by a hospital or
other covered facility
• Room and board, such as semiprivate or intensive
accommodations, general nursing care, meals and
special diets, and other hospital services
• Diagnostic tests
Note: Inpatient care to treat substance use disorder
includes room and board and ancillary charges for
confinements in a hospital/treatment facility for
rehabilitative treatment of alcoholism or substance use
disorder.
Note: You must get precertification of inpatient hospital
stays; failure to do so will result in a $500 penalty.
Preferred facilities: $350 per
admission copayment for
unlimited days (no deductible)
Member facilities: $450 per
admission copayment for
unlimited days, plus 35% of the
Plan allowance (no deductible)
Non-member facilities: 35% of the
Plan allowance for unlimited days
(no deductible), and any remaining
balance after our payment
Preferred facilities: $250 per day
copayment up to $1,500 per
admission for unlimited days
Member/Non-member facilities:
You pay all charges
Residential Treatment Center Standard Option Basic Option
Precertification prior to admission is required.
We cover inpatient care provided and billed by an RTC
when the care is medically necessary for the treatment of
a medical, mental health, and/or substance use disorder:
• Room and board, such as semiprivate room, nursing
care, meals, special diets, ancillary charges, and
covered therapy services when billed by the facility
Note: RTC benefits are not available for facilities licensed
as a skilled nursing facility, group home, halfway house,
or similar type facility.
Preferred facilities: $350 per
admission copayment for
unlimited days (no deductible)
Member facilities: $450 per
admission copayment for
unlimited days, plus 35% of the
Plan allowance (no deductible)
Non-member facilities: 35% of the
Plan allowance (no deductible),
and any remaining balance after
our payment
Preferred facilities: $250 per day
copayment up to $1,500 per
admission for unlimited days
Member/Non-member facilities:
You pay all charges
Residential Treatment Center - continued on next page
95 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(e)
Standard and Basic Option
Benefit Description You Pay
Residential Treatment Center (cont.) Standard Option Basic Option
Note: Benefits are not available for noncovered services,
including: respite care; outdoor residential programs;
services provided outside of the provider’s scope of
practice; recreational therapy; educational therapy;
educational classes; biofeedback; Outward Bound
programs; hippotherapy/equine therapy provided during
the approved stay; personal comfort items, such as guest
meals and beds, phone, television, beauty and barber
services; custodial or long-term care; and domiciliary
care provided because care in the home is not available or
is unsuitable.
Note: For outpatient residential treatment center services,
see the next Section.
Continued from previous page:
Note: Non-member facilities must,
prior to admission, agree to abide
by the terms established by the
Local Plan for the care of the
particular member and for the
submission and processing of
related claims.
Preferred facilities: $250 per day
copayment up to $1,500 per
admission for unlimited days
Member/Non-member facilities:
You pay all charges
Outpatient Hospital or Other Covered Facility Standard Option Basic Option
Outpatient services provided and billed by a covered
facility
Note: We cover outpatient mental health and substance
use disorder services or supplies provided and billed by
residential treatment centers at the levels shown here.
• Individual psychotherapy
• Group psychotherapy
• Pharmacologic (medication) management
• Partial hospitalization
• Intensive outpatient treatment
Preferred: 15% of the Plan
allowance (deductible applies)
Member: 35% of the Plan
allowance (deductible applies)
Non-member: 35% of the Plan
allowance (deductible applies).
You may also be responsible for
any difference between our
allowance and the billed amount.
Preferred: $35 copayment per
day per facility
Member/Non-member: You pay
all charges
Outpatient services provided and billed by a covered
facility
• Diagnostic tests
• Psychological testing
Note: A residential treatment center is a covered facility
for outpatient care (see Section 10, Definitions, for more
information). We cover inpatient mental health and
substance use disorder services or supplies provided and
billed by residential treatment centers, other than room
and board and inpatient physician care, at the levels
shown here.
Preferred: 15% of the Plan
allowance (deductible applies)
Member: 35% of the Plan
allowance (deductible applies)
Non-member: 35% of the Plan
allowance (deductible applies).
You may also be responsible for
any difference between our
allowance and the billed amount.
Preferred: Nothing
Member/Non-member: Nothing
Not Covered (Inpatient or Outpatient) Standard Option Basic Option
•
Educational or other counseling or training services
•
Services performed by a noncovered provider
•
Testing for and treatment of learning disabilities and
intellectual disability
•
Inpatient services performed or billed by residential
treatment centers, except as described in Sections 5(a)
and 5(e)
All chargesAll charges
Not Covered (Inpatient or Outpatient) - continued on next page
96 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(e)
Standard and Basic Option
Benefit Description You Pay
Not Covered (Inpatient or Outpatient) (cont.) Standard Option Basic Option
•
Services performed or billed by schools, halfway
houses, group homes or members of their staffs
Note: We cover professional services as described in
this section when they are provided and billed by a
covered professional provider acting within the scope
of their license.
•
Psychoanalysis or psychotherapy credited toward
earning a degree or furtherance of education or training
regardless of diagnosis or symptoms that may be
present
•
Services performed or billed by residential therapeutic
camps (e.g., wilderness camps, Outward Bound, etc.)
•
Hippotherapy/equine therapy (exercise on horseback)
•
Light boxes
•
Custodial or long-term care (see
Definitions
)
•
Costs associated with enabling or maintaining
providers’ telehealth (telemedicine) technologies, non-
interactive telecommunication such as email
communications, or asynchronous store-and-forward
telehealth services
All chargesAll charges
97 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(e)
Section 5(f). Prescription Drug Benefits
Standard and Basic Option
Important things you should keep in mind about these benefits for members enrolled in our regular
pharmacy program:
•We cover prescription drugs and supplies, as described below and on the following pages for members
enrolled in our regular pharmacy drug program.
•If there is no generic drug available, you must pay the brand-name cost-sharing amount when you receive a
brand-name drug.
•If there is a generic substitution available and you or your provider requests a brand-name drug, you will be
responsible for the applicable tier cost-share plus the difference in the cost of the brand-name and generic
drug. If the provider’s prescription is for the brand-name drug and indicates “dispense as written,” you are
responsible only for the applicable tier cost-share.
•If the cost of your prescription is less than your cost-sharing amount, you pay only the cost of your
prescription.
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
•Benefits for certain self-injectable (self-administered) drugs are provided only when they are dispensed by a
pharmacy under the pharmacy benefit. See the Tier 4 and Tier 5 specialty drug fills from a Preferred
pharmacy in the following pages.
•Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are
covered only when they are obtained from a non-pharmacy provider, such as a physician or facility (hospital
or ambulatory surgical center). See
Drugs From Other Sources
in this section for more information.
•Be sure to read Section 4,
Your Costs for Covered Services
, for valuable information about how cost-sharing
works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age
65 or over.
•Medication prices vary among different retail pharmacies, the Mail Service Prescription Drug Program, and
the Specialty Drug Pharmacy Program. Review purchasing options for your prescriptions to get the best
price. A drug cost tool is available at www.fepblue.org or call:
- Retail Pharmacy Program: 800-624-5060, TTY: 711
- Mail Service Prescription Drug Program: 800-262-7890, TTY: 711
- Specialty Drug Pharmacy Program: 888-346-3731, TTY: 711
•YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS AND SUPPLIES, and prior approval
must be renewed periodically. Prior approval is part of our Patient Safety and Quality Monitoring (PSQM)
program. Keep reading in this section for more information about the PSQM program and see Section 3 for
more information about prior approval. Our prior approval process may include step therapy, which requires
you to use a generic and/or preferred medication(s) before a non-preferred medication is covered.
•During the course of the year, we may move a brand-name drug from Tier 2 (preferred brand-name) to Tier 3
(non-preferred brand-name) if a generic equivalent becomes available or if new safety concerns arise. We
may also move a specialty drug from Tier 4 (preferred) to Tier 5 (non-preferred) if a generic equivalent or
biosimilar becomes available or if new safety concerns arise. If your drug is moved to a higher tier, your
cost-share will increase. If your drug is moved to noncovered, you pay the full cost of the medication. Tier
reassignments during the year are not considered benefit changes.
•A pharmacy restriction may be applied for clinically inappropriate use of prescription drugs and supplies.
•The Standard Option and Basic Option formularies both contain a comprehensive list of drugs under all
therapeutic categories with two exceptions: some drugs, nutritional supplements and supplies are not
covered; we may also exclude certain U.S. FDA-approved drugs when multiple generic equivalents/
alternative medications are available.
98 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
•Under Standard Option,
- You may use the Retail Pharmacy Program, the Mail Service Prescription Drug Program, or the Specialty
Drug Pharmacy Program to fill your prescriptions.
- There is no calendar year deductible for the Retail Pharmacy Program, the Mail Service Prescription Drug
Program, or the Specialty Drug Pharmacy Program.
•Under Basic Option,
- You must use Preferred retail pharmacies or the Specialty Drug Pharmacy Program in order to
receive benefits. Our specialty drug pharmacy is a Preferred pharmacy.
- The Mail Service Prescription Drug Program is available only to members with primary Medicare Part B
coverage.
- There is no calendar year deductible.
- We use a managed formulary for certain drug classes.
We will send each new enrollee a Plan identification card, which covers pharmacy and medical benefits. Standard Option members,
and Basic Option members with primary Medicare Part B coverage, are eligible to use the Mail Service Prescription Drug Program
and will also receive a mail service order form and a pre-addressed reply envelope.
There are important features you should be aware of. These include:
•Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or,
in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write
your prescriptions. See Section 5(i) for drugs purchased overseas.
•Where you can obtain them.
Under Standard Option, you may fill prescriptions at a Preferred retail pharmacy, at a Non-preferred retail pharmacy, through our
Mail Service Prescription Drug Program, or through the Specialty Drug Pharmacy Program. Under Standard Option, we pay a
higher level of benefits when you use a Preferred retail pharmacy, our Mail Service Prescription Drug Program, or the Specialty
Drug Pharmacy Program.
Under Basic Option, you must fill prescriptions only at a Preferred retail pharmacy or through the Specialty Drug Pharmacy
Program, in order to receive benefits. If Medicare Part B is your primary coverage, you may also fill prescriptions through our Mail
Service Prescription Drug Program.
Under Standard Option and Basic Option
Note: Neither the Mail Service Prescription Drug Program nor the Specialty Drug Pharmacy Program will fill your prescription for
a drug requiring prior approval until you have obtained prior approval. CVS Caremark, the program administrator, will hold your
prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be unable to be filled and
a letter will be mailed to you explaining the prior approval procedures.
Note: Both Preferred and Non-preferred retail pharmacies may offer options for ordering prescription drugs online. Drugs ordered
online may be delivered to your home; however, these online orders are not a part of the Mail Service Prescription Drug Program.
Note: Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be
available only through a Preferred retail pharmacy.
•What is covered.
Under Basic Option, we use a managed formulary for certain drug classes. If you purchase a drug in a class included in the
managed formulary that is not on the managed formulary, you will pay the full cost of that drug since that drug is not covered under
your benefit.
99 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Under Standard Option and Basic Option
Note: Both formularies include lists of preferred drugs that are safe, effective and appropriate for our members, and are available at
lower costs than non-preferred drugs. If your physician prescribed a more expensive non-preferred drug for you, we may ask that
they prescribe a preferred drug instead; we encourage you to do the same. If you purchase a drug that is not on our preferred drug
list, your cost will be higher. Your cooperation with our cost-savings efforts helps keep your premium affordable.
Note: Some drugs, nutritional supplements, and supplies are not covered (see later in this section); we may also exclude certain U.
S. FDA-approved drugs when multiple generic equivalents/alternative medications are available. If you purchase a drug, nutritional
supplement, or supply that is not covered, you will be responsible for the full cost of the item.
Note: Before filling your prescription, please check the preferred/non-preferred status of the drug. Other than changes
resulting from new drugs or safety issues, the preferred drug list is updated periodically during the year. Changes to the preferred
drug list are not considered benefit changes.
Note: Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the tier
assignments for formulary drugs, we work with our Pharmacy and Medical Policy Committee, a group of physicians and
pharmacists who are not employees or agents of, nor have financial interest in, the Blue Cross and Blue Shield Service Benefit
Plan. The Committee meets quarterly to review new and existing drugs to assist us in our assessment. Drugs determined to be of
equal therapeutic value and similar safety and efficacy are then evaluated on the basis of cost. The Committee’s recommendations,
together with our evaluation of the relative cost of the drugs, determine the placement of formulary drugs on a specific tier. Using
lower cost preferred drugs will provide you with a high-quality, cost-effective prescription drug benefit.
Our payment levels are generally categorized as:
Tier 1: Includes generic drugs
Tier 2: Includes preferred brand-name drugs
Tier 3: Includes non-preferred brand-name drugs
Tier 4: Includes preferred specialty drugs
Tier 5: Includes non-preferred specialty drugs
You can view both the Standard Option and Basic Option formularies, which include the preferred drug list for each, on our website
at www.fepblue.org or call 800-624-5060, TTY: 711, for assistance. Changes to the formulary are not considered benefit changes.
Any savings we receive on the cost of drugs purchased under this Plan from drug manufacturers are credited to the reserves held for
this Plan.
•Generic equivalents
Generic equivalent drugs have the same active ingredients as their brand-name equivalents. By filling your prescriptions (or those
of family members covered by the Plan) at a retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard
Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug
Program, you authorize the pharmacist to substitute any available U.S. FDA-approved generic equivalent, unless you or your
physician specifically requests a brand-name drug and indicates “dispense as written.” Keep in mind that Basic Option members
must use Preferred providers in order to receive benefits. See Section 10,
Definitions
, for more information about generic
alternatives and generic equivalents.
•Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your
prescription drug utilization, including the names of your prescribing physicians, to any treating physicians or dispensing
pharmacies.
•These are the dispensing limitations.
Standard Option: Subject to manufacturer packaging and your prescriber’s instructions, you may purchase up to a 90-day supply
of covered drugs and supplies through the Retail Pharmacy Program. You may purchase a supply of more than 21 days up to 90
days through the Mail Service Prescription Drug Program for a single copayment.
100 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Basic Option: When you fill Tier 1 (generic), Tier 2 (preferred brand-name), and Tier 3 (non-preferred brand-name) prescriptions
at a Preferred retail pharmacy, you may purchase up to a 30-day supply for a single copayment, or up to a 90-day supply for
additional copayments unless otherwise noted. Members with primary Medicare Part B coverage may purchase a supply of more
than 21 days up to 90 days through the Mail Service Prescription Drug Program for a single copayment.
Under Standard Option and Basic Option
Benefits for Tier 4 and Tier 5 specialty drugs purchased at a retail pharmacy are limited to one purchase of up to a 30-day supply
for each prescription dispensed. All refills must be obtained through the Specialty Drug Pharmacy Program. Benefits for the first
three fills of each Tier 4 or Tier 5 specialty drug are limited to a 30-day supply. Benefits are available for a 90-day supply after the
third fill of the specialty drug.
Note: Certain drugs such as narcotics may have additional limits or requirements as established by the U.S. FDA or by national
scientific or medical practice guidelines (such as Centers for Disease Control and Prevention, American Medical Association, etc.)
on the quantities that a pharmacy may dispense. In addition, pharmacy dispensing practices are regulated by the state where they
are located and may also be determined by individual pharmacies. Due to safety requirements, some medications are dispensed as
originally packaged by the manufacturer and we cannot make adjustments to the packaged quantity or otherwise open or split
packages to create 22, 30, and 90-day supplies of those medications. In most cases, refills cannot be obtained until 75% of the
prescription has been used. Controlled substances cannot be refilled until 80% of the prescription has been used. Controlled
substances are medications that can cause physical and mental dependence, and have restrictions on how they can be filled and
refilled. They are regulated and classified by the DEA (Drug Enforcement Administration) based on how likely they are to cause
dependence. Call us or visit our website if you have any questions about dispensing limits. Please note that in the event of a
national or other emergency, or if you are a reservist or National Guard member who is called to active military duty, you should
contact us regarding your prescription drug needs.
Note: Benefits for certain self-injectable (self-administered) drugs are provided only when they are dispensed by a pharmacy under
the pharmacy benefit. Medical benefits will be provided for a once-per-lifetime dose per therapeutic category of drugs dispensed by
your provider or any non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B
coverage. See later in this section for Tier 4 and Tier 5 specialty drug fills from a Preferred pharmacy.
Note: Benefits for certain auto-immune infusion medications (Remicade, Renflexis and Inflectra) are provided only when obtained
by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). See
Drugs From Other Sources
in this Section for more information.
Patient Safety and Quality Monitoring (PSQM)
We have a special program to promote patient safety and monitor healthcare quality. Our Patient Safety and Quality Monitoring
(PSQM) program features a set of closely aligned programs that are designed to promote the safe and appropriate use of medications.
Examples of these programs include:
•Prior approval – This program requires that approval be obtained for certain prescription drugs and supplies before we provide
benefits for them.
•Safety checks – Before your prescription is filled, we perform quality and safety checks for usage precautions, drug interactions,
drug duplication, excessive use, and frequency of refills.
•Quantity allowances – Specific allowances for several medications are based on U.S. FDA-approved recommendations, national
scientific and generally accepted standards of medical practice guidelines (such as Centers for Disease Control and Prevention,
American Medical Association, etc.), and manufacturer guidelines.
For more information about our PSQM program, including listings of drugs subject to prior approval or quantity allowances, visit our
website at www.fepblue.org or call the Retail Pharmacy Program at 800-624-5060, TTY: 711.
101 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Prior Approval
As part of our Patient Safety and Quality Monitoring (PSQM) program, you must make sure that your physician obtains prior
approval for certain prescription drugs and supplies in order to use your prescription drug coverage. In providing prior
approval, we may limit benefits to quantities prescribed in accordance with generally accepted standards of medical, dental, or
psychiatric practice in the United States. Our prior approval process may include step therapy, which requires you to use a generic
and/or preferred medication(s) before a non-preferred medication is covered. Prior approval must be renewed periodically. To
obtain a list of these drugs and supplies and to obtain prior approval request forms, call the Retail Pharmacy Program at
800-624-5060, TTY: 711. You can also obtain the list and forms through our website at www.fepblue.org. Please read Section 3 for
more information about prior approval.
Please note that updates to the list of drugs and supplies requiring prior approval are made periodically during the year. New drugs
and supplies may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval
criteria are not considered benefit changes.
Note: If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the drug
or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for
instructions on how to file prescription drug claims.
Note: It is your responsibility to know the prior approval authorization expiration date for your medication. We encourage you to work
with your physician to obtain prior approval renewal in advance of the expiration date.
Standard Option Generic Incentive Program
Your cost-share will be waived for the first 4 generic prescriptions filled (and/or refills ordered) per drug if you purchase a brand-
name drug on the Generic Incentive Program List while a member of the Service Benefit Plan and then change to a corresponding
generic drug replacement while still a member of the Plan.
•If you switch from one generic drug to another, you will be responsible for your copayment.
Note: The list of eligible generic drug replacements may change and is not considered a benefit change. For the most up-to-date
information, please visit www.fepblue.org/en/benefit-plans/coverage/pharmacy/generic-incentive-program or call us using any of the
numbers listed at the beginning of this section.
Medical Foods
The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider and are medically
necessary to prevent clinical deterioration in members at nutritional risk.
To receive benefits, products must meet the definition of medical food (See Section 10, Definitions).
Members must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by
modification of diet alone.
Coverage is provided as follows:
•Inborn errors of amino acid metabolism
•Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to
thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited
to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or
powders mixed to become formulas)
•Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
Note: A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior
authorization are required every benefit year for inborn errors of metabolism and tube feeding.
Note: See Section 5(a), Medical Supplies, for our coverage of medical foods and nutritional supplements when administered by
catheter or nasogastric tube under the medical benefit.
102 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Here is how to obtain your prescription drugs and supplies:
•Make sure you have your Plan ID card when you are ready to purchase your prescription.
•Go to any Preferred retail pharmacy, or
•Visit the website of your retail pharmacy to request your prescriptions online and delivery, if available.
•For a listing of Preferred retail pharmacies, call the Retail Pharmacy Program at 800-624-5060, TTY: 711, or visit our website,
www.fepblue.org.
Note: Retail pharmacies that are Preferred for prescription drugs are not necessarily Preferred for durable medical equipment (DME)
and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical
supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
Note: For prescription drugs billed by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown
below for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a
Preferred pharmacy. See later in this section for benefit information about prescription drugs supplied by Non-preferred retail
pharmacies.
Benefit Description You Pay
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section.
There is no calendar year deductible under Basic Option.
Covered Medication and Supplies Standard Option Basic Option
Preferred Retail Pharmacies
Covered drugs and supplies, such as:
• Drugs, vitamins and minerals, and nutritional
supplements that by Federal law of the United States
require a prescription for their purchase
• Drugs for the diagnosis and treatment of infertility
• Drugs for IVF – limited to 3 cycles annually (prior
approval required)
Note: Drugs used for IVF must be purchased through
the pharmacy drug program and you must meet our
definition of infertility.
• Drugs associated with covered artificial insemination
procedures
• Drugs to treat gender dysphoria (gonadotropin
releasing hormone (GnRH) antagonists and
testosterones)
• Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives
• Medical foods
• Insulin, diabetic test strips, lancets, and tubeless insulin
delivery systems (See Section 5(a) for our coverage of
insulin pumps with tubes.)
• Needles and disposable syringes for the administration
of covered medications
Tier 1 (generic drug): $7.50
copayment for each purchase of
up to a 30-day supply ($22.50
copayment for a 31 to 90-day
supply) (no deductible)
Note: You pay a $5 copayment for
each purchase of up to a 30-day
supply ($15 copayment for a 31 to
90-day supply) when Medicare
Part B is primary.
Note: You may be eligible to
receive your first 4 generic
prescriptions filled (and/or refills
ordered) at no charge when you
change from certain brand-name
drugs to a corresponding generic
drug replacement, as previously
described.
Tier 2 (preferred brand-name
drug): 30% of the Plan allowance
for each purchase of up to a 90-
day supply (no deductible)
Tier 3 (non-preferred brand-name
drug): 50% of the Plan allowance
for each purchase of up to a 90-
day supply (no deductible)
Tier 4 (preferred specialty drug):
30% of the Plan allowance (no
deductible), limited to one
purchase of up to a 30-day supply
Tier 1 (generic drug): $15
copayment for each purchase of
up to a 30-day supply ($40
copayment for a 31 to 90-day
supply)
Tier 2 (preferred brand-name
drug): $60 copayment for each
purchase of up to a 30-day supply
($180 copayment for a 31 to 90-
day supply)
Tier 3 (non-preferred brand-name
drug): 60% of the Plan allowance
($90 minimum) for each purchase
of up to a 30-day supply ($250
minimum for a 31 to 90-day
supply)
Tier 4 (preferred specialty drug):
$85 copayment limited to one
purchase of up to a 30-day supply
Tier 5 (non-preferred specialty
drug): $110 copayment limited to
one purchase of up to a 30-day
supply
When Medicare Part B is
primary, you pay the following:
Tier 1 (generic drug): $10
copayment for each purchase of
up to a 30-day supply ($30
copayment for a 31 to 90-day
supply)
Covered Medication and Supplies - continued on next page
103 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefit Description You Pay
Covered Medication and Supplies (cont.) Standard Option Basic Option
• Clotting factors and anti-inhibitor complexes for the
treatment of hemophilia
Note: For a list of the Preferred Network Long-Term Care
pharmacies, call 800-624-5060, TTY: 711.
Note: For coordination of benefits purposes, if you need a
statement of Preferred retail pharmacy benefits in order to
file claims with your other coverage when this Plan is the
primary payor, call the Retail Pharmacy Program at
800-624-5060, TTY: 711, or visit our website at www.
fepblue.org.
Note: We waive your cost-share for available forms of
generic contraceptives and for brand-name contraceptives
that have no generic equivalent or generic alternative
when purchased from a Preferred retail pharmacy.
Continued from previous page:
Tier 5 (non-preferred specialty
drug): 30% of the Plan allowance
(no deductible), limited to one
purchase of up to a 30-day supply
Continued from previous page:
Tier 2 (preferred brand-name
drug): $50 copayment for each
purchase of up to a 30-day supply
($150 copayment for a 31 to 90-
day supply)
Tier 3 (non-preferred brand-name
drug): 50% of the Plan allowance
($60 minimum) for each purchase
of up to a 30-day supply ($175
minimum for a 31 to 90-day
supply)
Tier 4 (preferred specialty drug):
$80 copayment limited to one
purchase of up to a 30-day supply
Tier 5 (non-preferred specialty
drug): $100 copayment limited to
one purchase of up to a 30-day
supply
Non-preferred Retail Pharmacies45% of the Plan allowance
(Average wholesale price – AWP),
plus any difference between our
allowance and the billed amount
(no deductible)
Note: If you use a Non-preferred
retail pharmacy, you must pay the
full cost of the drug or supply at
the time of purchase and file a
claim with the Retail Pharmacy
Program to be reimbursed. Please
refer to Section 7 for instructions
on how to file prescription drug
claims.
All charges
Mail Service Prescription Drug Program
For Standard Option and Basic Option members when
Medicare Part B is Primary, if your doctor orders more
than a 21-day supply of covered drugs or supplies, up to a
90-day supply, you can use this service for your
prescriptions and refills.
Please refer to Section 7 for instructions on how to use
the Mail Service Prescription Drug Program.
Note: You must obtain prior approval for certain drugs
before Mail Service will fill your prescription. See
Section 3.
Note: Not all drugs are available through the Mail Service
Prescription Drug Program. There are no specialty drugs
available through the Mail Service Program.
Tier 1 (generic drug): $15
copayment (no deductible)
Note: You pay a $10 copayment
per generic prescription filled
(and/or refill ordered) when
Medicare Part B is primary.
Note: You may be eligible to
receive your first 4 generic
prescriptions filled (and/or refills
ordered) at no charge when you
change from certain brand-name
drugs to a corresponding generic
drug replacement, as previously
stated.
When Medicare Part B is
primary, you pay the following:
Tier 1 (generic drug): $20
copayment
Tier 2 (preferred brand-name
drug): $100 copayment
Tier 3 (non-preferred brand-name
drug): $125 copayment
When Medicare Part B is not
primary: No benefits
Covered Medication and Supplies - continued on next page
104 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefit Description You Pay
Covered Medication and Supplies (cont.) Standard Option Basic Option
Note: Please keep reading for information about the
Specialty Drug Pharmacy Program.
Note: We waive your cost-share for available forms of
generic contraceptives and for brand-name contraceptives
that have no generic equivalent or generic alternative.
Contact Us
: If you have any questions about this
program, or need assistance with your Mail Service drug
orders, please call 800-262-7890, TTY: 711.
Note: If the cost of your prescription is less than your
copayment, you pay only the cost of your prescription.
The Mail Service Prescription Drug Program will charge
you the lesser of the prescription cost or the copayment
when you place your order. If you have already sent in
your copayment, they will credit your account with any
difference.
Continued from previous page:
Tier 2 (preferred brand-name
drug): $90 copayment (no
deductible)
Tier 3 (non-preferred brand-name
drug): $125 copayment (no
deductible)
Continued from previous page:
Note: Although you do not have
access to the Mail Service
Prescription Drug Program, you
may request home delivery of
prescription drugs you purchase
from Preferred retail pharmacies
offering options for online
ordering.
Specialty Drug Pharmacy Program
We cover specialty drugs that are listed on the Service
Benefit Plan Specialty Drug List. This list is subject to
change. For the most up-to-date list, call the phone
number below or visit our website, www.fepblue.org.
(See Section 10 for the definition of "specialty drugs.")
Each time you order a new specialty drug or refill, a
Specialty Drug pharmacy representative will work with
you. See Section 7 for more details about the Program.
Note: Benefits for the first three fills of each Tier 4 or
Tier 5 specialty drug are limited to a 30-day supply.
Benefits are available for a 31 to 90-day supply after the
third fill.
Note: Due to manufacturer restrictions, a small number of
specialty drugs may only be available through a Preferred
retail pharmacy. You will be responsible for paying only
the copayments shown here for specialty drugs affected
by these restrictions.
Contact Us
: If you have any questions about this
program, or need assistance with your specialty drug
orders, please call 888-346-3731, TTY: 711.
Tier 4 (preferred specialty drug):
$65 copayment for each purchase
of up to a 30-day supply ($185
copayment for a 31 to 90-day
supply) (no deductible)
Tier 5 (non-preferred specialty
drug): $85 copayment for each
purchase of up to a 30-day supply
($240 copayment for a 31 to 90-
day supply) (no deductible)
Tier 4 (preferred specialty drug):
$85 copayment for each purchase
of up to a 30-day supply ($235
copayment for a 31 to 90-day
supply)
Tier 5 (non-preferred specialty
drug): $110 copayment for each
purchase of up to a 30-day supply
($300 copayment for a 31 to 90-
day supply)
When Medicare Part B is
primary, you pay the following:
Tier 4 (preferred specialty drug):
$80 copayment for each purchase
of up to a 30-day supply ($210
copayment for a 31 to 90-day
supply)
Tier 5 (non-preferred specialty
drug): $100 copayment for each
purchase of up to a 30-day supply
($255 copayment for a 31 to 90-
day supply)
Asthma Medications
Preferred Retail Pharmacies:
Note: See Section 3 for information about drugs and
supplies that require prior approval.
Tier 1 (generic drug): $5
copayment (no deductible)
Tier 2 (preferred brand-name
drug): 20% of the Plan allowance
(no deductible)
Tier 1 (generic drug): $5
copayment for each purchase of
up to a 90-day supply
Tier 2 (preferred brand-name
drug): $35 copayment for each
purchase of up to a 30-day supply
($105 copayment for a 31 to 90-
day supply)
Covered Medication and Supplies - continued on next page
105 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefit Description You Pay
Covered Medication and Supplies (cont.) Standard Option Basic Option
Asthma Medications (cont.)
Continued from previous page:
When Medicare Part B is
primary, you pay the following:
Tier 1 (generic drug): $5
copayment
Tier 2 (preferred brand-name
drug): $30 copayment for each
purchase of up to a 30-day supply
($90 copayment for a 31 to 90-
day supply)
Mail Service Prescription Drug Program:
Note: You must obtain prior approval for certain drugs
before Mail Service will fill your prescription. See
Section 3.
Note: See earlier in this section for Tier 3, 4 and 5
prescription drug benefits.
Tier 1 (generic drug): $5
copayment (no deductible)
Tier 2 (preferred brand-name
drug): $65 copayment (no
deductible)
When Medicare Part B is
primary, you pay the following:
Tier 1 (generic drug): $5
copayment
Tier 2 (preferred brand-name
drug): $75 copayment
Other Preferred Diabetic Medications, Test Strips,
and Supplies
Preferred Retail Pharmacies:
Tier 2 (preferred diabetic
medications and supplies): 20% of
the Plan allowance for each
purchase of up to a 90-day supply
(no deductible)
Tier 2 (preferred insulins): $35
copayment for each purchase of
up to a 30-day supply ($65
copayment for a 31 to 90-day
supply) (no deductible)
Non-preferred retail pharmacies:
You pay all charges
Tier 2 (preferred diabetic
medications and supplies): $35
copayment for each purchase of
up to a 30-day supply ($65
copayment for a 31 to 90-day
supply)
When Medicare Part B is
primary, you pay the following:
Tier 2 (preferred brand-name
drugs): $30 copayment for each
purchase of up to a 30-day supply
($60 copayment for a 31 to 90-
day supply)
Mail Service Prescription Drug Program:
Note: See earlier in this section for Tier 2, 3, 4, and 5
prescription drug benefits.
Benefits will be provided for syringes, pens and pen
needles and test strips at Tier 2 (diabetic medications and
supplies) for Standard Option members, and Basic Option
members with primary Medicare Part B, through the Mail
Service Prescription Drug Program.
Tier 2 (preferred brand-name
drugs): $40 copayment for each
purchase of up to a 90-day supply
(no deductible)
When Medicare Part B is
primary, you pay the following:
Tier 2 (preferred brand-name
drugs): $50 copayment for each
purchase of up to a 90-day supply
Covered Medication and Supplies - continued on next page
106 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefit Description You Pay
Covered Medication and Supplies (cont.) Standard Option Basic Option
Diabetic Meter Program
Members with diabetes may obtain one glucose meter kit
every 365 days at no cost through our Diabetic Meter
Program. To use this program, you must call the phone
number listed below and request one of the eligible types
of meters. The types of glucose meter kits available
through the program are subject to change.
To order your free glucose meter kit, call us toll-free at
855-582-2024, Monday through Friday, from 9 a.m. to 7
p.m., Eastern Time, or visit our website at www.fepblue.
org. The selected meter kit will be sent to you within 7 to
10 days of your request.
Note: Contact your physician to obtain a new prescription
for the test strips and lancets to use with the new meter.
Nothing for a glucose meter kit
ordered through the Diabetic
Meter Program
Nothing for a glucose meter kit
ordered through the Diabetic
Meter Program
107 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
FEP MEDICARE PRESCRIPTION DRUG PROGRAM
Important things you should keep in mind about these benefits for members enrolled in our (Medicare
Part D), FEP Medicare Prescription Drug Program:
•We cover prescription drugs and supplies, as detailed on the following pages for members enrolled in our
FEP Medicare Prescription Drug Program.
•Members with Medicare Part A and/or Part B primary are eligible for the benefits under the FEP Medicare
Prescription Drug Program.
•If you were originally group enrolled and chose to disenroll prior to January 1, 2024, you will not be able to
rejoin the FEP Medicare Prescription Drug Program until the next enrollment period.
•If you opt-out from the group enrollment or disenroll any time after January 1, 2024, you will not be eligible
to re-enroll prior to the next enrollment period.
•For additional information about who is eligible for this program and when, or to dispute your claim, please
visit us at www.fepblue.org/medicarerx
•We may provide additional coverage for prescription drugs not included in your Medicare Part D benefit. For
more information about your share of the cost or which prescription drugs may or may not be covered, please
call 888-338-7737, TTY 711.
•If there is no generic drug available, you must pay the brand-name cost-sharing amount when you receive a
brand-name drug.
•Members enrolled in the FEP Medicare Prescription Drug program have no coverage for drugs obtained and/
or purchased overseas.
•If the cost of your prescription is less than your cost-sharing amount, you pay only the cost of your
prescription.
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
•Certain medications may be covered under Medicare Part B or Medicare Part D, depending on the condition
being treated.
•Be sure to read Section 4,
Your Costs for Covered Services
, for valuable information about how cost-sharing
works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age
65 or over.
•Medication prices vary among different pharmacies in our network. Review purchasing options for your
prescriptions to get the best price. A drug cost tool is available at www.fepblue.org/medicarerx or call
888-338-7737, TTY: 711
•YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS AND SUPPLIES, and prior approval
must be renewed periodically. Our prior approval process may include step therapy, which requires you to
use a generic and/or preferred medication(s) before a non-preferred medication is covered.
•During the course of the year, we may move a brand-name drug from Tier 2 (preferred brand-name) to Tier 3
(non-preferred brand-name) if a generic equivalent becomes available or if new safety concerns arise. If your
drug is moved to a higher tier, your cost-share will increase. If your drug is moved to noncovered, you pay
the full cost of the medication. Tier reassignments during the year are not considered benefit changes.
•A pharmacy restriction may be applied for clinically inappropriate use of prescription drugs and supplies.
•The Standard Option and Basic Option formularies both contain a comprehensive list of drugs under all
therapeutic categories with two exceptions: some drugs, nutritional supplements and supplies are not
covered; we may also exclude certain U.S. FDA-approved drugs when multiple generic equivalents/
alternative medications are available. See
Not Covered
later in this section for details.
108 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
We will send each new enrollee a Plan identification card, which covers pharmacy and medical benefits.
There are important features you should be aware of. These include:
•Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or,
in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write
your prescriptions.
•Where you can obtain them.
Under Standard Option and Basic Option, you may fill prescriptions at a pharmacy that participates in our nationwide network.
The network includes retail pharmacies, mail service pharmacies and specialty pharmacies. You may also receive your medication
from a long-term care pharmacy when your care is handled in or by a long-term care facility. You will receive a copy of the
pharmacy directory, which lists all pharmacies participating in our network, in your enrollment package. You may also go online to
our webpage www.fepblue.org/medicaredrugprogram for a complete listing.
Note: Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be
available only through select pharmacies in our network.
•What is covered.
Under Standard Option and Basic Option
Both formularies include lists of preferred drugs that are safe, effective and appropriate for our members, and are available at lower
costs than non-preferred drugs. If you purchase a drug that is not on our preferred drug list, your cost will be higher. Your
cooperation with our cost-savings efforts helps keep your premium affordable.
Note: Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the tier
assignments for formulary drugs, we work with the CVS Caremark National Pharmacy and Therapeutics Committee, a group of
physicians and pharmacists who are not employees or agents of, nor have any financial interest in the Blue Cross and Blue Shield
Service Benefit Plan. The committee meets quarterly to review new and existing drugs to assist us in our assessment.
Our payment levels are generally categorized as:
Tier 1: Includes generic drugs
Tier 2: Includes preferred brand-name drugs
Tier 3: Includes non-preferred brand-name drugs
Tier 4: Includes preferred specialty drugs
You can view both the Standard Option and Basic Option formularies, which include the preferred drug list for each, on our website
at www.fepblue.org or call 888-338-7737, TTY: 711, for assistance. Changes to the formulary are not considered benefit changes.
•Generic equivalents
Generic equivalent drugs have the same active ingredients as their brand-name equivalents. By filling your prescriptions (or those
of family members covered by the Plan) at a pharmacy participating in our network, you authorize the pharmacist to substitute any
available U.S. FDA-approved generic equivalent, unless you or your physician specifically requests a brand-name drug and
indicates “dispense as written.” See Section 10,
Definitions
, for more information about generic alternatives and generic
equivalents.
•Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your
prescription drug utilization, including the names of your prescribing physicians, to any treating physicians or dispensing
pharmacies.
•These are the dispensing limitations.
Standard Option and Basic Option: Subject to manufacturer packaging and your prescriber’s instructions, you may purchase up
to a 90-day supply of covered drugs and supplies through the pharmacy network.
109 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Under Standard Option and Basic Option
Note: Certain drugs such as narcotics may have additional limits or requirements as established by the U.S. FDA or by national
scientific or medical practice guidelines (such as Centers for Disease Control and Prevention, American Medical Association, etc.)
on the quantities that a pharmacy may dispense. In addition, pharmacy dispensing practices are regulated by the state where they
are located and may also be determined by individual pharmacies. Due to safety requirements, some medications are dispensed as
originally packaged by the manufacturer and we cannot make adjustments to the packaged quantity or otherwise open or split
packages to create 22, 30, and 90-day supplies of those medications. In most cases, refills cannot be obtained until 75% of the
prescription has been used. Controlled substances cannot be refilled until 80% of the prescription has been used. Controlled
substances are medications that can cause physical and mental dependence, and have restrictions on how they can be filled and
refilled. They are regulated and classified by the DEA (Drug Enforcement Administration) based on how likely they are to cause
dependence. Call us or visit our website if you have any questions about dispensing limits. Please note that in the event of a
national or other emergency, or if you are a reservist or National Guard member who is called to active military duty, you should
contact us regarding your prescription drug needs. See the contact information below.
Important Contact Information
FEP Medicare Prescription Drug Program: 888-338-7737, TTY: 711; or www.fepblue.org/medicarerx
Prior Approval
You must make sure that your physician obtains prior approval for certain prescription drugs and supplies in order to use
your prescription drug coverage. In providing prior approval, we may limit benefits to quantities prescribed in accordance with
generally accepted standards of medical, dental, or psychiatric practice in the United States. Our prior approval process may include
step therapy, which requires you to use a generic and/or preferred medication(s) before a non-preferred medication is covered. Prior
approval must be renewed periodically. To obtain a list of these drugs and supplies and to obtain prior approval request forms, call
the FEP Medicare Prescription Drug Program 888-338-7737, TTY: 711. You can also obtain the list and forms through our website at
www.fepblue.org. Please read Section 3 for more information about prior approval.
Please note that updates to the list of drugs and supplies requiring prior approval are made periodically during the year. New drugs
and supplies may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval
criteria are not considered benefit changes.
Note: If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the drug
or supply at the time of purchase and file a claim with the FEP Medicare Prescription Drug Program to be reimbursed. Please refer to
Section 7 for instructions on how to file prescription drug claims.
Note: It is your responsibility to know the prior approval authorization expiration date for your medication. We encourage you to work
with your physician to obtain prior approval renewal in advance of the expiration date.
Medical Foods
The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider, and are medically
necessary to prevent clinical deterioration in members at nutritional risk.
To receive benefits, products must meet the definition of medical food (see Section 10, Definitions).
Members must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by
modification of diet alone.
Coverage is provided as follows:
•Inborn errors of amino acid metabolism
•Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to
thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited
to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or
powders mixed to become formulas)
•Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
110 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Note: A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior
authorization are required every benefit year for inborn errors of metabolism and tube feeding.
Note: See Section 5(a) Medical Supplies for our coverage of medical foods and nutritional supplements when administered by
catheter or nasogastric tube under the medical benefit.
Here is how to obtain your Prescription Drugs and Supplies.
•Make sure you have your Plan ID card when you are ready to purchase your prescription.
•Go to any network pharmacy, or
•Visit the website of your retail pharmacy to request your prescriptions online and delivery, if available.
Note: Pharmacies within our network for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and
medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical
supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
Note: For prescription drugs billed by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown
on the following pages for drugs obtained from a pharmacy in our network, as long as the pharmacy supplying the prescription drugs
to the facility is a network pharmacy.
Catastrophic Maximums
Each individual enrolled in the FEP Medicare Prescription Drug Program has a separate and lower out-of-pocket catastrophic
protection maximum for the drugs purchased while covered under this Program.
Under Standard Option, this separate catastrophic maximum is $2,000
Under Basic Option, this separate catastrophic maximum is $3,250.
This amount accumulates toward the out-of-pocket catastrophic protection maximums described in Section 4 for combined medical
and drug expenses for those not enrolled under the FEP Medicare Prescription Drug Program.
Benefit Description You Pay
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section.
There is no calendar year deductible under Basic Option.
Covered Medications and Supplies Standard Option Basic Option
Retail Pharmacies
Covered drugs and supplies, such as:
• Drugs, vitamins and minerals, and nutritional
supplements that by Federal law of the United States
require a prescription for their purchase
• Drugs for the diagnosis and treatment of infertility
• Drugs for IVF – limited to 3 cycles annually (prior
approval required)
Note: Drugs used for IVF must be purchased through
the pharmacy drug program and you must meet our
definition of infertility.
• Drugs associated with covered artificial insemination
procedures
• Drugs to treat gender dysphoria (gonadotropin
releasing hormone (GnRH) antagonists and
testosterones)
Tier 1 (generic drug): $5
copayment for each purchase of
up to a 30-day supply ($15
copayment for a 31 to 90-day
supply) (no deductible)
Tier 2 (preferred brand-name
drug): 15% of the Plan allowance
for each purchase of up to a 90-
day supply (no deductible)
Tier 3 (non-preferred brand-name
drug): 50% of the Plan allowance
for each purchase of up to a 90-
day supply (no deductible)
Tier 4 (preferred specialty drug):
$60 copayment for each purchase
of up to a 30-day supply ($170
copayment for a 31 to 90-day
supply) (no deductible)
Tier 1 (generic drug): $10
copayment for each purchase of
up to a 30-day supply ($30
copayment for a 31 to 90-day
supply)
Tier 2 (preferred brand-name
drug): $45 copayment for each
purchase of up to a 30-day supply
($135 copayment for a 31 to 90-
day supply)
Tier 3 (non-preferred brand-name
drug): 50% of the Plan allowance
($60 minimum) for each purchase
of up to a 30-day supply ($175
minimum for a 31 to 90-day
supply)
Covered Medications and Supplies - continued on next page
111 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefit Description You Pay
Covered Medications and Supplies (cont.) Standard Option Basic Option
• Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives
Note: We waive your cost-share for available forms of
generic contraceptives and for brand-name contraceptives
that have no generic equivalent or generic alternative
when purchased from a network retail pharmacy.
• Medical foods
• Insulin, diabetic test strips, lancets, and tubeless insulin
delivery systems (See Section 5(a) for our coverage of
insulin pumps with tubes.)
• Needles and disposable syringes for the administration
of covered medications
• Clotting factors and anti-inhibitor complexes for the
treatment of hemophilia
Note: For a list of the Network Long-Term Care
pharmacies, call 888-338-7737, TTY: 711.
See previous page Continued from previous page:
Tier 4 (preferred specialty drug):
$75 copayment for each purchase
of up to a 30-day supply; ($195
for 31 to 90-day supply)
Mail Service Prescription Drug Program
For members enrolled in the FEP Medicare Prescription
Drug Program, if your doctor orders more than a 21-day
supply of covered drugs or supplies, up to a 90-day
supply, you can use this service for your prescriptions and
refills.
Please refer to Section 7 for instructions on how to use
the Mail Service Prescription Drug Program.
Note: You must obtain prior approval for certain drugs
before Mail Service will fill your prescription. See
Section 3.
Note: Not all drugs are available through the Mail Service
Prescription Drug Program.
Note: We waive your cost-share for available forms of
generic contraceptives and for brand-name contraceptives
that have no generic equivalent or generic alternative.
Contact Us: If you have any questions about this
program, or need assistance with your Mail Service drug
orders, please call 800-262-7890, TTY: 711.
Tier 1 (generic drug): $5
copayment (no deductible)
Tier 2 (preferred brand-name
drug): $85 copayment (no
deductible)
Tier 3 (non-preferred brands):
$125 copayment (no deductible)
Tier 4 (specialty-drugs): $150
copayment (no deductible)
Tier 1 (generic drug): $15
copayment
Tier 2 (preferred brand-name
drug): $95 copayment
Tier 3 (non-preferred brands):
$125 copayment
Tier 4 (specialty-drugs): $150
copayment
Covered Medications and Supplies - continued on next page
112 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefit Description You Pay
Covered Medications and Supplies (cont.) Standard Option Basic Option
Note: If the cost of your prescription is less than your
copayment, you pay only the cost of your prescription.
The Mail Service Prescription Drug Program will charge
you the lesser of the prescription cost or the copayment
when you place your order. If you have already sent in
your copayment, they will credit your account with any
difference.
Tier 1 (generic drug): $5
copayment (no deductible)
Tier 2 (preferred brand-name
drug): $85 copayment (no
deductible)
Tier 3 (non-preferred brands):
$125 copayment (no deductible)
Tier 4 (specialty-drugs): $150
copayment (no deductible)
Tier 1 (generic drug): $15
copayment
Tier 2 (preferred brand-name
drug): $95 copayment
Tier 3 (non-preferred brands):
$125 copayment
Tier 4 (specialty-drugs): $150
copayment
Asthma Medications
Network Retail Pharmacies:
Note: See Section 3 for information about drugs and
supplies that require prior approval.
Tier 1 (generic drug): $5
copayment (no deductible)
Tier 2 (preferred brand-name
drug): 10% of the Plan allowance
(no deductible)
Tier 1 (generic drug): $5
copayment for each purchase of
up to a 90-day supply
Tier 2 (preferred brand-name
drug): $30 copayment for each
purchase of up to a 30-day supply
($90 copayment for a 31 to 90-
day supply)
Mail Service Prescription Drug Program
Note: You must obtain prior approval for certain drugs
before Mail Service will fill your prescription. See
Section 3.
Note: See earlier in this section for Tier 3 and Tier 4
prescription drug benefits
Tier 1 (generic drug): $5
copayment (no deductible)
Tier 2 (preferred brand-name
drug): $65 copayment (no
deductible)
Tier 1 (generic drug): $5
copayment
Tier 2 (preferred brand-name
drug): $75 copayment
Other Preferred Diabetic Medications, Test Strips,
and Supplies
Network Retail Pharmacies:
Tier 2 (preferred diabetic
medications and supplies): 10% of
the Plan allowance for each
purchase of up to a 90-day supply
(no deductible)
Tier 2 (preferred insulins): $35
copayment for each purchase of
up to a 30-day supply ($65
copayment for a 31 to 90-day
supply) (no deductible)
Tier 2 (preferred diabetic
medications and supplies): $30
copayment for each purchase of
up to a 30-day supply ($60
copayment for a 31 to 90-day
supply)
Mail Service Prescription Drug Program:
Note: See earlier in this section for Tier 2, 3, and 4
prescription drug benefits.
Benefits will be provided for syringes, pens and pen
needles and test strips at Tier 2 (diabetic medications and
supplies) for those enrolled in the FEP Medicare
Prescription Drug Program when obtained through the
Mail Service Prescription Drug Program.
Tier 2 (preferred brand-name
drug): $40 copayment for each
purchase of up to a 90-day supply
(no deductible)
Tier 2 (preferred brand-name
drugs): $50 copayment for each
purchase of up to a 90-day supply
The pharmacy benefits starting here to the end of the section apply to all covered members, unless otherwise noted.
113 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefits Description You Pay
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section.
There is no calendar year deductible under Basic Option.
Covered Medications and Supplies Standard Option Basic Option
Smoking and Tobacco Cessation Medications
If you are a covered member, you may be eligible to
obtain specific prescription generic and brand-name
smoking and tobacco cessation medications at no
charge. Additionally, you may be eligible to obtain
over-the-counter (OTC) smoking and tobacco
cessation medications, prescribed by your physician,
at no charge. These benefits are only available when
you use a Preferred retail pharmacy. To qualify, create
a Tobacco Cessation Quit Plan using Daily Habits.
For more information, see Section 5(h). The Quit
Plan is not required for those covered under the FEP
Medicare Prescription Drug Program.
Note: There may be age restrictions based on U.S.
FDA guidelines for these medications.
The following medications are covered through this
program:
• Generic medications available by prescription:
- Bupropion ER 150 mg tablet
- Bupropion SR 150 mg tablet
- Varenicline 0.5 mg tablets
- Varenicline 1 mg tablets
- Varenicline starting pack
• Brand-name medications available by prescription:
- Nicotrol cartridge inhaler
- Nicotrol NS spray 10 mg/ml
• Over-the-counter (OTC) medications
Note: To receive benefits for over-the-counter (OTC)
smoking and tobacco cessation medications, you
must have a physician’s prescription for each OTC
medication that must be filled by a pharmacist at a
Preferred retail pharmacy.
Note: These benefits apply only when all of the
criteria listed above are met. Regular prescription
drug benefits will apply to purchases of smoking and
tobacco cessation medications not meeting these
criteria. Benefits are not available for over-the-
counter (OTC) smoking and tobacco cessation
medications except as described above.
Note: See Section 5(a) for our coverage of smoking
and tobacco cessation treatment, counseling, and
classes.
Preferred retail pharmacy: Nothing
(no deductible)
Non-preferred retail pharmacy: You
pay all charges
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You
pay all charges
Covered Medications and Supplies - continued on next page
114 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefits Description You Pay
Covered Medications and Supplies (cont.) Standard Option Basic Option
Anti-hypertensive Medications
Preferred Retail Pharmacies:
Note: See Section 3 for information about drugs and
supplies that require prior approval.
Tier 1 (generic drug): $3 copayment
(no deductible)
Tier 1 (generic drug): $5 copayment
for each purchase of up to a 90-day
supply
Mail Service Prescription Drug Program:
Note: You must obtain prior approval for certain
drugs before Mail Service will fill your prescription.
Note: See earlier in this section for Tier 2, 3, 4, and 5
prescription drug benefits.
Tier 1 (generic drug): $3 copayment
(no deductible)
When Medicare Part B is
primary, you pay the following:
Tier 1 (generic drug): $5 copayment
• Over-the-counter (OTC) contraceptive drugs and
devices, limited to:
- Emergency contraceptive pills
- Condoms
- Spermicides
- Sponges
Note: We provide benefits in full for OTC
contraceptive drugs and devices when the
contraceptives meet U.S. FDA standards for OTC
products. To receive benefits, you must use a retail
pharmacy and present the pharmacist with a written
prescription from your physician.
Preferred retail pharmacy: Nothing
(no deductible)
Non-preferred retail pharmacy: You
pay all charges
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You
pay all charges
Immunizations when provided by a Preferred retail
pharmacy that participates in our vaccine network
(see below) and administered in compliance with
applicable state law and pharmacy certification
requirements.
Note: Our vaccine network is a network of Preferred
retail pharmacies that have agreements with us to
administer one or more routine immunizations. Check
with your pharmacy or call our Retail Pharmacy
Program at 800-624-5060, TTY: 711, to find out
which vaccines your pharmacy can provide.
Preferred retail pharmacy: Nothing
(no deductible)
Non-preferred retail pharmacy: You
pay all charges (except as noted
below)
Note: You pay nothing for influenza
(flu) vaccines obtained at Non-
preferred retail pharmacies.
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You
pay all charges (except as noted
below)
Note: You pay nothing for influenza
(flu) vaccines obtained at Non-
preferred retail pharmacies.
Metformin and metformin extended release
(excluding osmotic and modified release generic
drugs)
Preferred Retail Pharmacies:Tier 1 (generic drug): $1 copayment
for each purchase of up to a 90-day
supply (no deductible)
Tier 1 (generic drug): $1 copayment
for each purchase of up to a 90-day
supply
Mail Service Prescription Drug Program:Tier 1 (generic drug): $1 copayment
for each purchase of up to a 90-day
supply (no deductible)
When Medicare Part B is
primary, you pay the following:
Tier 1 (generic drug): $1 copayment
for each purchase of up to a 90-day
supply
Covered Medications and Supplies - continued on next page
115 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefits Description You Pay
Covered Medications and Supplies (cont.) Standard Option Basic Option
Medications to promote better health as
recommended under the Patient Protection and
Affordable Care Act (the “Affordable Care Act”),
limited to:
• Iron supplements for children from age 6 months
through 12 months
• Oral fluoride supplements for children from age 6
months through 5 years
• Folic acid supplements, 0.4 mg to 0.8 mg, for
individuals capable of pregnancy
• Low-dose aspirin (81 mg per day) for pregnant
members at risk for preeclampsia
• Aspirin for men age 45 through 79 and women age
50 through 79
• Generic cholesterol-lowering statin drugs
Note: Benefits are not available for acetaminophen,
ibuprofen
,
naproxen, etc.
Note: Benefits for these medications are subject to the
dispensing limitations described earlier and are
limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred
retail pharmacy and present a written prescription
from your physician to the pharmacist.
Note: A complete list of USPSTF-recommended
preventive care services is available online at: www.
healthcare.gov/preventive-care-benefits. See Section
5(a) for information about other covered preventive
care services.
Preferred retail pharmacy: Nothing
(no deductible)
Non-preferred retail pharmacy: You
pay all charges
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You
pay all charges
Generic medications to reduce breast cancer risk for
women, age 35 or over, who have not been diagnosed
with any form of breast cancer
Note: Your physician must send a completed
Coverage Request Form to CVS Caremark before
you fill the prescription. Call CVS Caremark at
800-624-5060, TTY: 711, to request this form. You
can also obtain the Coverage Request Form through
our website at www.fepblue.org. This is not required
if you are covered under the FEP Medicare
Prescription Drug Program.
Preferred retail pharmacy: Nothing
(no deductible)
Non-preferred retail pharmacy: You
pay all charges
Mail Service Prescription Drug
Program: Nothing (no deductible)
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You
pay all charges
When Medicare Part B is
primary, you pay the following:
Mail Service Prescription Drug
Program: Nothing
Covered Medications and Supplies - continued on next page
116 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefits Description You Pay
Covered Medications and Supplies (cont.) Standard Option Basic Option
We cover the first prescription filled for certain bowel
preparation medications for colorectal cancer
screenings with no member cost-share. We also cover
certain antiretroviral therapy medications for HIV
for those at risk but who do not have HIV. You can
view the list of covered medications on our website at
www.fepblue.org or call 800-624-5060, TTY: 711, for
assistance.
Preferred retail pharmacy: Nothing
(no deductible)
Non-preferred retail pharmacy: You
pay all charges
Mail Service Prescription Drug
Program: Nothing (no deductible)
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You
pay all charges
When Medicare Part B is
primary, you pay the following:
Mail Service Prescription Drug
Program: Nothing
Opioid Reversal Agents: Tier 1 medications limited to
generic naloxone nasal spray and injectable
Preferred Retail Pharmacies:Tier 1: Nothing for the purchase of
up to a 90-day supply per calendar
year (no deductible)
Note: Once you have purchased
amounts of these medications in a
calendar year that are equivalent to
a 90-day supply combined, all Tier
1 fills thereafter are subject to the
corresponding cost-share.
Tier 1: Nothing for the purchase of
up to a 90-day supply per calendar
year
Note: Once you have purchased
amounts of these medications in a
calendar year that are equivalent to
a 90-day supply combined, all Tier
1 fills thereafter are subject to the
corresponding cost-share.
Non-preferred Retail Pharmacies:You pay all charges You pay all charges
Mail Service Prescription Drug Program:
Tier 1: Nothing for the purchase of
up to a 90-day supply per calendar
year (no deductible)
When Medicare Part B is
primary, you pay the following:
Tier 1: Nothing for the purchase of
up to a 90-day supply per calendar
year
Note: Once you have purchased amounts of these
medications in a calendar year that are equivalent to a
combined 90-day supply through any of our
pharmacy programs, all Tier 1 fills thereafter are
subject to the corresponding cost-share.
Not covered:
•
Remicade, Renflexis, and Inflectra are not covered
for prescriptions obtained from a retail pharmacy,
Mail Service Prescription or through the Specialty
Drug Program
•
Medical supplies such as dressings and antiseptics
•
Drugs and supplies for cosmetic purposes
•
Supplies for weight loss
•
Drugs for orthodontic care, dental implants, and
periodontal disease
•
Drugs used in conjunction with non-covered
assisted reproductive technology (ART) and
assisted insemination procedures
All chargesAll charges
Covered Medications and Supplies - continued on next page
117 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefits Description You Pay
Covered Medications and Supplies (cont.) Standard Option Basic Option
•
Drugs used in conjunction with IVF that exceed the
covered 3 per year annual cycle limitation
described in this section
•
Insulin and diabetic supplies except when obtained
from a retail pharmacy or through the Mail Service
Prescription Drug Program, or except when
Medicare Part B is primary or you are enrolled in
the FEP Medicare Prescription Drug Program (see
Section 5(a))
•
Medications and orally taken nutritional
supplements that do not require a prescription
under Federal law even if your doctor prescribes
them or if a prescription is required under your
state law
Note: See previous benefits in this section for our
coverage of medications recommended under the
Affordable Care Act and for smoking and tobacco
cessation medications.
•
Medical foods administered orally are not covered
if not obtained at a retail pharmacy or through the
Mail Service Prescription Drug Program
Note: See Section 5(a) for our coverage of medical
foods when administered by catheter or nasogastric
tube.
•
Products and foods other than liquid formulas or
powders mixed to become formulas; foods and
formulas readily available in a retail environment
and marketed for persons without medical
conditions; low-protein modified foods (e.g.,
pastas, breads, rice, sauces and baking mixes);
nutritional supplements, energy products; and
similar items
Note: See Section 5(a) for our coverage of medical
foods and nutritional supplements when
administered by catheter or nasogastric tube.
•
Infant formula other than previously described in
this section and in Section 5(a)
•
Drugs for which prior approval has been denied or
not obtained
•
Drugs and supplies related to sexual dysfunction or
sexual inadequacy
•
Drugs and covered-drug-related supplies for the
treatment of gender dysphoria if not obtained from
a retail pharmacy or through the Mail Service
Prescription Drug Program or Specialty Drug
Pharmacy Program as previously described in this
section
•
Drugs purchased through the mail or internet from
pharmacies outside the United States by members
located in the United States
All chargesAll charges
Covered Medications and Supplies - continued on next page
118 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefits Description You Pay
Covered Medications and Supplies (cont.) Standard Option Basic Option
•
Over-the-counter (OTC) contraceptive drugs and
devices, except as previously described in this
section
•
Drugs used to terminate pregnancy
•
Sublingual allergy desensitization drugs, except as
described in Section 5(a)
All chargesAll charges
Drugs From Other Sources Standard Option Basic Option
Covered prescription drugs and supplies not obtained
at a retail pharmacy, through the Specialty Drug
Pharmacy Program, or, for Standard Option members
and Basic Option members with primary Medicare
Part B, through the Mail Service Prescription Drug
Program. This includes drugs and supplies covered
only under the medical benefit.
Note: Prior approval is required for certain high-cost
drugs obtained outside one of our pharmacy
programs. Contact the customer service number on
the back of your ID card or visit us at www.fepblue.
org/highcostdrugs for a list of these drugs. See
Section 3 for more information on prior approval.
Note: We cover drugs and supplies purchased
overseas as shown here, as long as they are the
equivalent to drugs and supplies that by Federal law
of the United States require a prescription. Please
refer to Section 5(i) for more information.
Note: For covered prescription drugs and supplies
purchased outside of the United States, Puerto Rico,
and the U.S. Virgin Islands, please submit claims on
an Overseas Claim Form. See Section 5(i) for
information on how to file claims for overseas
services.
• Please refer to the Sections indicated for additional
benefit information related to drugs obtained from
other sources:
- Physician’s office – Section 5(a)
- Facility (inpatient or outpatient) – Section 5(c)
- Hospice agency – Section 5(c)
• Please refer to information discussed previously in
this section for prescription drugs obtained from a
Preferred retail pharmacy, that are billed for by a
skilled nursing facility, nursing home, or extended
care facility.
Preferred: 15% of the Plan
allowance (deductible applies)
Participating professional provider:
35% of the Plan allowance
(deductible applies)
Non-participating professional
provider: 35% of the Plan allowance
(deductible applies) plus any
difference between our allowance
and the billed amount
Member facilities: 35% of the Plan
allowance (deductible applies)
Non-member facilities: 35% of the
Plan allowance (deductible applies),
plus any difference between our
allowance and the billed amount
Preferred: 30% of the Plan
allowance
Participating professional provider:
You pay all charges
Non-participating professional
provider: You pay all charges
Member/Non-member facilities:
You pay all charges
Drugs From Other Sources - continued on next page
119 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Standard and Basic Option
Benefits Description You Pay
Drugs From Other Sources (cont.) Standard Option Basic Option
For members covered under our regular pharmacy
drug program:
• Auto-immune infusion medications: Remicade,
Renflexis and Inflectra
Note: Benefits for certain auto-immune infusion
medications (limited to Remicade, Renflexis and
Inflectra) are covered only when they are obtained by
a non-pharmacy provider, such as a physician or
facility (hospital or ambulatory surgical center).
Members covered under the FEP Medicare
Prescription Drug Program may obtain these drugs
under their pharmacy benefits.
Preferred: 10% of the Plan
allowance (deductible applies)
Participating professional provider:
15% of the Plan allowance
(deductible applies)
Non-participating professional
provider: 15% of the Plan allowance
(deductible applies) plus any
difference between our allowance
and the billed amount
Member facilities: 15% of the Plan
allowance (deductible applies)
Non-member facilities: 15% of the
Plan allowance (deductible applies),
plus any difference between our
allowance and billed amount.
Preferred: 15% of the Plan
allowance
Participating professional provider:
You pay all charges
Non-participating professional
provider: You pay all charges
Member/Non-member facilities:
You pay all charges
120 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(f)
Section 5(g). Dental Benefits
Standard and Basic Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
•If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your
FEHB Plan will be the primary payor for any covered services and your FEDVIP Plan will be secondary to
your FEHB Plan. See Section 9,
Coordinating Benefits with Medicare and Other Coverage
, for additional
information.
•Be sure to read Section 4,
Your Costs for Covered Services
, for valuable information about how cost-sharing
works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age
65 or over.
•Note: We cover inpatient and outpatient hospital care, as well as anesthesia administered at the facility, to
treat children up to age 22 with severe dental caries. We cover these services for other types of dental
procedures only when a non-dental physical impairment exists that makes hospitalization necessary to
safeguard the health of the patient (even if the dental procedure itself is not covered). See Section 5(c) for
inpatient and outpatient hospital benefits.
•Under Standard Option,
- The calendar year deductible of $350 per person ($700 per Self Plus One or Self and Family enrollment)
applies only to the accidental injury benefit below.
•Under Basic Option,
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits, except in cases of dental care resulting
from an accidental injury as described below.
Benefit Description You Pay
Accidental Injury Benefit Standard Option Basic Option
We provide benefits for services, supplies, or
appliances for dental care necessary to promptly
repair injury to sound natural teeth required as a
result of, and directly related to, an accidental
injury. To determine benefit coverage, we may
require documentation of the condition of your
teeth before the accidental injury, documentation
of the injury from your provider(s), and a treatment
plan for your dental care. We may request updated
treatment plans as your treatment progresses.
Note: An accidental injury is an injury caused by
an external force or element such as a blow or fall
and that requires immediate attention. Injuries to
the teeth while eating are not considered accidental
injuries.
Preferred: 15% of the Plan allowance
(deductible applies)
Participating: 35% of the Plan
allowance (deductible applies)
Non-participating: 35% of the Plan
allowance (deductible applies), plus
any difference between our allowance
and the billed amount
Note: Under Standard Option, we
first provide benefits as shown in the
Schedule of Dental Allowances on
the following pages. We then pay
benefits as shown here for any
balances.
$35 copayment for associated oral
evaluations
30% of the Plan allowance for all
other care
Note: We provide benefits for
accidental dental injury care in
cases of medical emergency when
performed by Preferred or non-
preferred providers. See Section
5(d) for the criteria we use to
determine if emergency care is
required. You are responsible for the
applicable cost-share amounts as
shown above. If you use a non-
preferred provider, you may also be
responsible for any difference
between our allowance and the billed
amount.
Note: All follow-up care must be
performed and billed for by Preferred
providers to be eligible for benefits.
Accidental Injury Benefit - continued on next page
121 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(g)
Standard and Basic Option
Benefit Description You Pay
Accidental Injury Benefit (cont.) Standard Option Basic Option
Note: A sound natural tooth is a tooth that is
whole or properly restored (restoration with
amalgams or resin-based composite fillings only);
is without impairment, periodontal, or other
conditions; and is not in need of the treatment
provided for any reason other than an accidental
injury. For purposes of this Plan, a tooth previously
restored with a crown, inlay, onlay, or porcelain
restoration, or treated by endodontics, is not
considered a sound natural tooth.
See previous page See previous page
Dental Benefits
What is Covered
Standard Option dental benefits are presented in the chart on the following page.
Basic Option dental benefits appear later in this section.
Note: See Section 5(b) for our benefits for oral and maxillofacial surgery, and Section 5(c) for our benefits for hospital services
(inpatient/outpatient) in connection with dental services, available under both Standard Option and Basic Option.
Preferred Dental Network
All Local Plans contract with Preferred dentists who are available in most areas. Preferred dentists agree to accept a negotiated,
discounted amount called the Maximum Allowable Charge (MAC) as payment in full for the following services. They will also file
your dental claims for you. Under Standard Option, you are responsible, as an out-of-pocket expense, for the difference between the
amount specified in this Schedule of Dental Allowances and the MAC. To find a Preferred dentist near you, visit www.fepblue.org/
provider to use our National Doctor & Hospital Finder, or call us at the customer service phone number on the back of your ID card.
You can also call us to obtain a copy of the applicable MAC listing.
Note: Dentists and oral surgeons who are in our Preferred Dental Network for routine dental care are not necessarily Preferred
providers for other services covered by this Plan under other benefit provisions (such as the surgical benefit for oral and maxillofacial
surgery). Call us at the customer service phone number on the back of your ID card to verify that your provider is Preferred for the
type of care (e.g., routine dental care or oral surgery) you are scheduled to receive.
122 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(g)
Standard and Basic Option
Standard Option Dental Benefits
Under Standard Option, we pay billed charges for the following services, up to the amounts shown per service as listed in the
Schedule of Dental Allowances below and on the following page. This is a complete list of dental services covered under this benefit
for Standard Option. There are no deductibles, copayments, or coinsurance. When you use non-preferred dentists, you pay all charges
in excess of the listed fee schedule amounts. For Preferred dentists, you pay the difference between the fee schedule amount and the
MAC described on the previous page.
Standard Option Dental Benefits Standard Option Only
Covered Service We Pay to
Age 13
We Pay Age 13
and Over
You Pay
Clinical oral evaluations
Periodic oral evaluation
(up to 2 per person per
calendar year)
Limited oral evaluation
Comprehensive oral evaluation
Detailed and extensive oral evaluation
$12
$14
$14
$14
$8
$9
$9
$9
All charges in excess of the
scheduled amounts listed to the left
Note: For services performed by
dentists and oral surgeons in our
Preferred Dental Network, you pay
the difference between the amounts
listed to the left and the Maximum
Allowable Charge (MAC).
Diagnostic imaging
Intraoral complete series
$36 $22
All charges in excess of the
scheduled amounts listed to the left
Note: For services performed by
dentists and oral surgeons in our
Preferred Dental Network, you pay
the difference between the amounts
listed to the left and the Maximum
Allowable Charge (MAC).
Palliative treatment
Palliative treatment of dental pain – minor procedure
Protective restoration
$24
$24
$15
$15
All charges in excess of the
scheduled amounts listed to the left
Note: For services performed by
dentists and oral surgeons in our
Preferred Dental Network, you pay
the difference between the amounts
listed to the left and the Maximum
Allowable Charge (MAC).
Preventive
Prophylaxis – adult
(up to 2 per person per calendar
year)
Prophylaxis – child
(up to 2 per person per calendar
year)
Topical application of fluoride or fluoride varnish (
up
to 2 per person per calendar year
)
---
$22
$13
$16
$14
$8
All charges in excess of the
scheduled amounts listed to the left
Note: For services performed by
dentists and oral surgeons in our
Preferred Dental Network, you pay
the difference between the amounts
listed to the left and the Maximum
Allowable Charge (MAC).
Not covered: Any service not specifically listed aboveNothingNothingAll charges
123 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(g)
Standard and Basic Option
Basic Option Dental Benefits
Under Basic Option, we provide benefits for the services listed below. You pay a $35 copayment for each evaluation, and we pay any
balances up to the Maximum Allowable Charge previously described in this section. This is a complete list of dental services covered
under this benefit for Basic Option. You must use a Preferred dentist in order to receive benefits. For a list of Preferred dentists, visit
www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer service phone number on the back
of your ID card.
Basic Option Dental Benefits Basic Option Only
Covered Service We Pay You Pay
Clinical oral evaluations
Periodic oral evaluation*
Limited oral evaluation
Comprehensive oral evaluation*
*Benefits are limited to a combined total of 2 evaluations
per person per calendar year
Preferred: All charges in excess of
your $35 copayment
Participating/Non-participating:
Nothing
Preferred: $35 copayment per
evaluation
Participating/Non-participating:
You pay all charges
Diagnostic imaging
Intraoral – complete series including bitewings (
limited to
1 complete series every 3 years
)
Preferred: All charges in excess of
your $35 copayment
Participating/Non-participating:
Nothing
Preferred: $35 copayment per
evaluation
Participating/Non-participating:
You pay all charges
Preventive
Prophylaxis – adult
(up to 2 per calendar year)
Prophylaxis – child
(up to 2 per calendar year)
Topical application of fluoride or fluoride varnish – for
children only
(up to 2 per calendar year)
Sealant – per tooth, first and second molars only
(once
per tooth for children up to age 16 only)
Preferred: All charges in excess of
your $35 copayment
Participating/Non-participating:
Nothing
Preferred: $35 copayment per
evaluation
Participating/Non-participating:
You pay all charges
Not covered: Any service not specifically listed aboveNothingAll charges
124 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(g)
Section 5(h). Wellness and Other Special Features
Standard and Basic Option
Special Feature Description
Stay connected to your health and get the answers you need when you need them by using Health Tools
24 hours a day, 365 days a year. Go to www.fepblue.org or call 888-258-3432 toll-free to check out
these valuable easy-to-use services:
• Talk directly with a Registered Nurse any time of the day or night via phone, secure email, or live
chat. Ask questions and get medical advice. Please keep in mind that benefits for any healthcare
services you may seek after using Health Tools are subject to the terms of your coverage under this
Plan.
• Personal Health Record – Access your secure online personal health record for information such
as the medications you’re taking, recent test results, and medical appointments. Update, store, and
track health-related information at any time.
• Blue Health Assessment – Complete this online health and lifestyle questionnaire and receive
additional assistance with your healthcare expenses. See the following for more information.
• Daily Habits – Manage your health proactively by setting and managing health goals, create a plan
of care, track your progress, and pursue healthy activities. Daily Habits offers members a
combination of guidance, support, and resources.
• Tobacco Cessation Incentive Program – If you would like to quit smoking, you can participate in
this program and receive tobacco cessation products at no charge. Create a Tobacco Cessation Quit
Plan using our online coaching tool, Daily Habits. You will then be eligible to receive certain
smoking and tobacco cessation medications at no charge. Both prescription and over-the-counter
(OTC) tobacco cessation products obtained from a Preferred retail pharmacy are included in this
program. See Section 5(f) for more information.
Note: There may be age restrictions based on U.S. FDA guidelines for these medications.
• Health Topics and WebMD Videos offer an extensive variety of educational tools using videos,
recorded messages, and colorful online materials that provide up-to-date information about a wide
range of health-related topics.
Health Tools
All Blue Cross and Blue Shield Plans provide TTY access for the hearing impaired to access
information and receive answers to their questions.
Services for the Deaf
and Hearing
Impaired
Our website, www.fepblue.org, adheres to the most current Section 508 Web accessibility standards to
ensure that visitors with visual impairments can use the site with ease.
Web Accessibility for
the Visually Impaired
Please refer to Section 5(i) for benefit and claims information for care you receive outside the United
States, Puerto Rico, and the U.S. Virgin Islands.
Travel Benefit/
Services Overseas
Our Healthy Families suite of resources is for families with children and teens, ages 2 to 19. Healthy
Families provides activities and tools to help parents teach their children about weight management,
nutrition, physical activity, and personal well-being. For more information, go to www.fepblue.org.
Healthy Families
The Diabetes Management Program is a program to help members with diabetes manage their
condition. All members with type 1 and type 2 diabetes, including those for whom Medicare is primary,
are eligible for this program. You will receive a free glucose meter and have unlimited test strips and
lancets shipped directly to you. Automated reordering is based on your usage. Personalized coaching
and support are also provided. The program offers live interventions triggered by acute alerts based on
your glucose meter test results. Member support is offered 24/7/365. For more information go to www.
fepblue.org/diabetes.
Diabetes
Management
Program
The Blue Health Assessment (BHA) questionnaire is an easy and engaging online health evaluation
program which can be completed in 10-20 minutes. Your BHA answers are evaluated to create a unique
health action plan. Based on the results of your BHA, you can select personalized goals, receive
supportive advice, and easily track your progress through our online coaching tool, Daily Habits.
Blue Health
Assessment
125 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(h)
Standard and Basic Option
When you complete your BHA, you are entitled to receive a $50 health account to be used for most
qualified medical expenses. For those with Self Plus One or Self and Family coverage, both the contract
holder and spouse are eligible for the $50 health account. We will send each eligible member a debit
card to access their account. Please keep your card for future use even if you use all of your health
account dollars; you may be eligible for wellness incentives in subsequent benefit years. We do not
send new cards to continuing participants until the card expires. If you leave the Service Benefit Plan,
any money remaining in your account will be forfeited.
In addition to the $50 health account, you are entitled to receive a maximum of $120 in additional credit
to your health account for achieving up to three personalized goals. After completing the BHA, you
may access Daily Habits to set personalized goals designed to improve your health through increased
exercise, healthier nutrition habits, managing your weight, reduced stress, better emotional health, or
goals that focus on managing a specific condition. We will add $40 to your health account for each goal
achieved, up to a maximum of three goals per year. By completing the BHA and a maximum of three
health goals, you can earn up to a total of $170 in health account dollars. You must complete the BHA
and your selected goals during the calendar year in order to receive these incentives.
Health account dollars are available only when you complete goals related to exercise, nutrition,
weight management, stress, emotional health, heart disease, heart failure, hypertension, chronic
obstructive pulmonary disease (COPD) and asthma and are limited to a maximum of three
completed goals per calendar year.
Note: In order to receive your incentives, you must complete all eligible activities no later than
December 31, 2024. Please allow ample time to complete all activities by this date.
Visit our website, www.fepblue.org, for more information and to complete the BHA so you can receive
your individualized results and begin working toward achieving your goals. You may also request a
printed BHA by calling 888-258-3432 toll-free.
The Hypertension Management Program gives members age 18 and older with hypertension
(otherwise known as high blood pressure) access to a free blood pressure monitor (BPM) to encourage
members to make healthier choices to reduce the potential for complications from cardiac disease. This
program is available to the contract holder and spouse who meet the following criteria.
You will be automatically enrolled in the program, and will be informed of your eligibility to receive a
free BPM after the following criteria are met:
• You complete the Blue Health Assessment (BHA), and indicate that you have been diagnosed with
hypertension.
• At least one medical claim has been processed during the past 12 months with a reported diagnosis
of hypertension.
Once you meet these criteria, you will be sent a letter advising you of your eligibility for the free BPM.
You are eligible to receive a free BPM every two calendar years. You must follow the directions in the
letter, which include taking the letter to your healthcare provider. Your provider is responsible for
documenting your most recent blood pressure reading, and identifying the appropriate BPM size for
you.
The BPM must be received through this program. Benefits are not available for BPMs for members
who do not meet the criteria or for those who obtain a BPM outside of this program. For more
information, call us at the phone number on the back of your ID card. See Section 5(f) for information
on preferred generic anti-hypertensive medications.
Hypertension
Management
Program
The Pregnancy Care Incentive Program is designed to encourage early and ongoing prenatal care that
improves baby’s birth weight and decreased risk of preterm labor. Pregnant members can earn a
Pregnancy Care Box (with pregnancy gifts and information) and $75 toward a health account to be used
for most qualified medical expenses. This incentive is in addition to other incentives described in this
brochure. All covered adult members, age 18 and over may be eligible for this incentive.
Pregnancy Care
Incentive Program
126 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(h)
Standard and Basic Option
To qualify for the Pregnancy Care Box, you must be pregnant. Information on the program is available
on our website, www.fepblue.org.
To qualify for the $75 incentive, you must meet the criteria above for the Pregnancy Care Box and send
us a copy of your healthcare provider’s medical record that confirms you had a prenatal care visit
during the first trimester of your pregnancy.
Information that must be included when submitting your medical record can be found on our website,
www.fepblue.org/maternity.
To receive the Pregnancy Care Box or the $75 incentive reward, members must complete all
requirements of the program during the benefit year, and either the first prenatal visit or the delivery
must occur during the benefit year. These incentives are offered per pregnancy and are limited to two
pregnancies per calendar year.
Financial incentives earned through participation in the Blue Health Assessment, personalized goals
through Daily Habits and the Pregnancy Care Incentive Program are limited to a total of $420 per
person per calendar year for the contract holder and spouse.
Annual Incentive
Limitation
Basic Option members enrolled in Medicare Part A and Part B are eligible to be reimbursed up to $800
per calendar year for their Medicare Part B premium payments. The account is used to reimburse
member-paid Medicare Part B premiums. For more information on how to obtain reimbursement,
please visit www.fepblue.org/mra or call 888-706-2583.
Reimbursement
Account for Basic
Option Members
Enrolled in Medicare
Part A and Part B
Visit MyBlue Customer eService at www.fepblue.org/myblue or use the fepblue mobile app to check
the status of your claims, change your address of record, request claim forms, request a duplicate or
replacement Service Benefit Plan ID card, and track how you use your benefits. Additional features
include:
• Online EOBs – You can view, download, and print your explanation of benefits (EOB) forms.
Simply log on to MyBlue Customer eService via www.fepblue.org/myblue and click on “View My
Claims”; from there you can search claims and select the “EOB” link next to each claim to access
your EOB. You can also access EOBs via the fepblue mobile app. Simply link to MyBlue, and click
on Claims.
• Opt In or Out of Mailed Paper EOBs – The Service Benefit Plan offers an environmentally
friendly way of accessing your EOBs via www.fepblue.org/myblue. You can opt in or out of
receiving mailed paper EOBs by following the on-screen instructions.
• Personalized Messages – Our EOBs provide a wide range of messages just for you and your
family, ranging from preventive care opportunities to enhancements to our online services.
• Financial Dashboard – Log in to MyBlue to access important information in real time, including
deductibles, out-of-pocket costs, remaining covered provider visits, medical claims, and pharmacy
claims. You also can review your year-to-date summary of completed claims, MyBlue Wellness
Card balance, and pharmacy spending throughout the year.
MyBlue
®
Customer
eService
Visit www.fepblue.org/provider to access our National Doctor & Hospital Finder and other nationwide
listings of Preferred providers.
National Doctor &
Hospital Finder
If you have a rare or chronic disease or have complex healthcare needs, the Service Benefit Plan offers
two types of Care Management Programs that provide assistance with the coordination of your care,
provide member education and clinical support.
Care Management
Programs
127 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(h)
Standard and Basic Option
• Case Management provides members who have acute or chronic complex healthcare needs with
the services and assistance of a licensed healthcare professional with a nationally recognized case
management certification. Case managers may be a registered nurse, licensed social worker, or
other licensed healthcare professional practicing within the scope of their license, who may work
with you and your providers to assess your healthcare needs, coordinate needed care and available
resources, evaluate the outcomes of your care, and support and monitor the progress of the
member’s treatment plan and healthcare needs. Some members may receive guidance and clinical
support for an acute healthcare need while others may benefit from a short-term case management
enrollment. Enrollment in case management requires your consent. Members in case management
are asked to provide verbal consent prior to enrollment in case management and must provide
written consent for case management.
• Disease Management supports members who have diabetes, asthma, chronic obstructive
pulmonary disease (COPD), coronary artery disease, or congestive heart failure by helping them
adopt effective self-care habits to improve the self-management of their condition. If you have been
diagnosed with any of these conditions, we may send you information about the programs available
to you in your area.
If you have any questions regarding these programs, including if you are eligible for enrollment and
assistance with enrollment, please contact us at the customer service phone number on the back of your
ID card.
Under the Blue Cross and Blue Shield Service Benefit Plan, our Case Management process may include
a flexible benefits option. This option allows professional case managers at Local Plans to assist
members with certain complex and/or chronic health issues by coordinating complicated treatment
plans and other types of complex patient care plans. Through the flexible benefits option, case
managers will review the member’s healthcare needs and may at our sole discretion, identify a less
costly alternative treatment plan for the member. The member (or their healthcare proxy) and provider
(s) must cooperate in the process. Case Management Program enrollment is required for eligibility.
Prior to the starting date of the alternative treatment plan, members who are eligible to receive services
through the flexible benefits option are required to sign and return a written consent for case
management and the alternative plan. If you and your provider agree with the plan, alternative benefits
will begin immediately and you will be asked to sign an alternative benefits agreement that includes
the terms listed below, in addition to any other terms specified in the agreement. We must receive the
consent for case management and the alternative benefits agreement signed by the member/
healthcare proxy before you receive any services included in the alternative benefits agreement.
• Alternative benefits will be made available for a limited period of time and are subject to our
ongoing review. You must cooperate with and participate in the review process. Your provider(s)
must submit the information necessary for our reviews. You and/or your healthcare proxy must
participate in care conferences and caregiver training as requested by your provider(s) or by us.
• We may revoke the alternative benefits agreement immediately at any time, if we discover we were
misled by the information given to us by you, your provider, or anyone else involved in your care,
or that you are not meeting the terms of the agreement.
• If we approve alternative benefits, we do not guarantee that they will be extended beyond the
limited time period and/or scope of the alternative benefits agreement or that they will be approved
in the future.
• The decision to offer alternative benefits is solely ours, and unless otherwise specified in the
alternative benefits agreement, we may at our sole discretion, withdraw those benefits at any time
and resume regular contract benefits.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Flexible Benefits
Option
128 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(h)
Standard and Basic Option
If you sign the alternative benefits agreement, we will provide the agreed-upon alternative benefits
for the stated time period, unless we are misled by the information given to us or circumstances change.
Benefits as stated in this brochure will apply to all services and dates of care not included in the
alternative benefits agreement. You or your provider may request an extension of the time period
initially approved for alternative benefits, no later than five business days prior to the end of the
alternative benefits agreement. We will review the request, including the services proposed as an
alternative and the cost of those services, but benefits as stated in this brochure will apply if we do not
approve your request.
Note: If we deny a request for precertification or prior approval of regular contract benefits, as stated in
this brochure, or if we deny regular contract benefits for services you have already received, you may
dispute our denial of regular contract benefits under the OPM disputed claims process (see Section 8).
Go to www.fepblue.org/telehealth or call 855-636-1579, TTY: 711, toll free to access on-demand,
affordable, high-quality care for adults and children experiencing non-emergency medical issues,
including treatment of minor acute conditions, dermatology care, counseling for behavioral health and
substance use disorder, and nutritional counseling.
Note: This benefit is available only through the contracted telehealth provider network.
Telehealth Services
Blue Cross and Blue Shield’s fepblue mobile application is available for download for both iOS and
Android mobile phones. The application provides members with 24/7 access to helpful features, tools
and information related to Blue Cross and Blue Shield Service Benefit Plan benefits. Members can log
in with their MyBlue
®
username and password to access personal healthcare information such as
benefits, out-of-pocket costs, deductibles (if applicable) and physician visit limits. They can also view
claims and approval status, view/share Explanations of Benefits (EOBs), view/share member ID cards,
locate in-network providers, and connect with our telehealth services.
The fepblue Mobile
Application
129 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(h)
Section 5(i). Services, Drugs, and Supplies Provided Overseas
Standard and Basic Option
If you travel or live outside the United States, Puerto Rico, and the U.S. Virgin Islands, you are still entitled to the benefits described
in this brochure. Unless otherwise noted in this Section, the same definitions, limitations, and exclusions also apply. Costs associated
with repatriation from an international location back to the United States are not covered. See Section 10 for a definition of
repatriation. See below and later in this section for the claims information we need to process overseas claims. We may request that
you provide complete medical records from your provider to support your claim. If you plan to receive healthcare services in a
country sanctioned by the Office of Foreign Assets Control (OFAC) of the U.S. Department of the Treasury, your claim must include
documentation of a government exemption under OFAC authorizing care in that country.
Please note that the requirements to obtain precertification for inpatient care and prior approval for those services listed in
Section 3 do not apply when you receive care overseas, with the exception of admissions for gender affirming surgery and
admissions to residential treatment centers and skilled nursing facilities. Prior approval is required for all non-emergent air
ambulance transport services for overseas members (refer to Section (c)). Protections offered under the NSA (see Section 3) do
not apply to overseas claims. Members enrolled in the FEP Medicare Prescription Drug Program have no coverage for drugs
obtained and/or purchased overseas.
We have a network of participating hospitals overseas that will file your claims for inpatient facility care for
you – without an advance payment for the covered services you receive. We also have a network of
professional providers who have agreed to accept a negotiated amount as payment in full for their services.
The Overseas Assistance Center can help you locate a hospital or physician in our network near where you
are staying. You may also view a list of our network providers on our website, www.fepblue.org. You will
have to file a claim to us for reimbursement for professional services unless you or your provider contacts the
Overseas Assistance Center in advance to arrange direct billing and payment to the provider.
If you are overseas and need assistance locating providers (whether in or out of our network), contact the
Overseas Assistance Center (provided by GeoBlue), by calling 804-673-1678. Members in the United States,
Puerto Rico, or the U.S. Virgin Islands should call 800-699-4337 or email the Overseas Assistance Center at
[email protected]. GeoBlue also offers emergency evacuation services to the nearest facility
equipped to adequately treat your condition, translation services, and conversion of foreign medical bills to
U.S. currency. You may contact one of their multilingual operators 24 hours a day, 365 days a year.
Overseas
Assistance
Center
For professional care you receive overseas, we provide benefits at Preferred benefit levels using either our
Overseas Fee Schedule, a customary percentage of the billed charge, or a provider-negotiated discount as our
Plan allowance. The Basic Option requirement to use Preferred providers in order to receive benefits
does not apply when you receive overseas care. Standard Option members have no deductible for
overseas services.
Under both Standard and Basic Options, when the Plan allowance is based on the Overseas Fee Schedule,
you pay any difference between our payment and the amount billed, in addition to any applicable
coinsurance and/or copayment amounts. When the Plan allowance is a provider-negotiated discount, you are
only responsible for your coinsurance and/or copayment amounts. You must also pay any charges for
noncovered services.
For inpatient facility care you receive overseas, we provide benefits at the Preferred level under both
Standard and Basic Options. For Basic Option, there is no member cost-share for admissions to a DoD
facility, or when the Overseas Assistance Center (provided by GeoBlue) has arranged direct billing or
acceptance of a guarantee of benefits with the facility. For all other inpatient facility care, Basic Option
members are responsible for the per admission copayment. Standard Option members have no cost-share for
inpatient facility care.
For outpatient facility care you receive overseas, we provide benefits at the Preferred level under both
Standard and Basic Options after you pay the applicable copayment or coinsurance. Standard Option
members have no deductible for overseas services.
Hospital and
professional
provider
benefits
130 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(i)
Standard and Basic Option
For dental care you receive overseas, we provide benefits as described in Section 5(g). Under Standard
Option, you must pay any difference between the Schedule of Dental Allowances and the dentist’s charge, in
addition to any charges for noncovered services. Under Basic Option, you must pay the $35 copayment plus
any difference between our payment and the dentist’s charge, as well as any charges for noncovered services.
For transport services you receive overseas, we provide benefits for transport services to the nearest
hospital equipped to adequately treat your condition when the transport services are medically necessary. We
provide benefits as described in Section 5(c) and Section 5(d). Benefits are not available for costs associated
with transportation to other than the closest hospital equipped to treat your condition. Under Standard and
Basic Options, members pay the applicable copayment.
For prescription drugs purchased at overseas pharmacies, we provide benefits at Preferred benefit levels,
using the billed charge as our Plan allowance. Under both Standard and Basic Options, members pay the
applicable coinsurance. Standard Option members are not required to meet the calendar year deductible when
they purchase drugs at pharmacies located overseas. See Section 5(f) for more information.
Pharmacy
benefits
Most overseas providers are under no obligation to file claims on behalf of our members. Follow the
procedures listed below to file claims for covered services and drugs you receive outside the United States,
Puerto Rico, and the U.S. Virgin Islands. You may need to pay for the services at the time you receive
them and then send a claim to us for reimbursement. We will provide translation and currency conversion
services for your overseas claims.
Overseas claims
payment
To file a claim for covered hospital and professional provider services received outside the United States,
Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Overseas Medical Claim Form, by mail,
fax, or internet, along with itemized bills from the provider. In completing the claim form, indicate whether
you want to be paid in U.S. dollars or in the currency reflected on the itemized bills, and if you want to
receive payment by check or bank wire. Use the following information to mail, fax, or submit your claim
electronically:
1. Mail: Federal Employee Program, Overseas Claims, P.O. Box 1568, Southeastern, PA 19399.
2. Fax: 001-610-293-3529. Be sure to first dial the AT&T Direct Access Code of the country from which
you are faxing the claim.
3. Internet: Go to the MyBlue portal on www.fepblue.org. If you are already a registered MyBlue portal
user, click on the “Health Tools” menu and, in the “Get Care” section, select “Submit Overseas Claim”
and follow the instructions for submitting a medical claim. If you are not yet a registered user, go to
MyBlue, click on the “Sign Up” link, and register to use the online filing process.
If you have questions about your medical claims, call us at 888-999-9862, using the AT&T Direct Access
Code of the country from which you are calling, or email us through our website ( www.fepblue.org) via the
MyBlue portal. You may also write to us at: Mailroom Administrator, FEP Overseas Claims, P.O. Box 14112,
Lexington, KY 40512-4112. You may obtain Overseas Medical Claim Forms from our website, by email at
[email protected], or from your Local Plan.
Filing overseas
claims
Drugs purchased overseas must be the equivalent to drugs that by Federal law of the United States require a
prescription. To file a claim for covered drugs and supplies you purchase from pharmacies outside the United
States, Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Retail Prescription Drug Overseas
Claim Form, along with itemized pharmacy receipts or bills. Timely filing for overseas pharmacy claims is
limited to one year from the prescription fill date. Use the following information to mail, fax, or submit your
claim electronically:
1. Mail: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057,
Phoenix, AZ 85072-2057.
2. Fax: 001-480-614-7674. Be sure to first dial the AT&T Direct Access Code of the country from which
you are faxing the claim.
3. Internet: Go to the MyBlue portal on www.fepblue.org. If you are already a registered MyBlue portal
user, click on the “Health Tools” menu and, in the “Get Care” section, select “Submit Overseas Claim”
and follow the instructions for submitting a pharmacy claim. If you are not yet a registered user, go to
MyBlue, click on the “Sign Up” link, and register to use the online filing process.
Filing a claim
for pharmacy
benefits
131 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(i)
Standard and Basic Option
Send any written inquiries concerning drugs you purchase overseas to: Blue Cross and Blue Shield Service
Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057. You may obtain FEP
Retail Prescription Drug Overseas Claim forms for your drug purchases by visiting our website, www.
fepblue.org, by writing to the address above, or by calling us at 888-999-9862, using the AT&T Direct
Access Code of the country from which you are calling.
While overseas, you may be able to order your prescription drugs through the Mail Service Prescription Drug
Program or our Specialty Drug Pharmacy Program as long as all of the following conditions are met:
• Your address includes a U.S. ZIP code (such as with APO and FPO addresses and in U.S. territories),
• The prescribing physician is licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, and
has a National Provider Identifier (NPI), and
• Delivery of the prescription is permitted by law and is in accordance with the manufacturer’s guidelines.
See Section 5(f) for more information about Preferred retail pharmacies with online ordering options, the
Mail Service Prescription Drug Program, and the Specialty Drug Pharmacy Program.
The Mail Service Prescription Drug Program is available to Standard Option members and to Basic Option
members with primary Medicare Part B coverage.
Note: In most cases, temperature-sensitive drugs cannot be sent to APO/FPO addresses due to the special
handling they require.
Note: We are unable to ship drugs, through either our Mail Service Prescription Drug Program or our
Specialty Drug Pharmacy Program, to overseas countries that have laws restricting the importation of
prescription drugs from any other country. This is the case even when a valid APO or FPO address is
available. If you are living in such a country, you may obtain your prescription drugs from a local overseas
pharmacy and submit a claim to us for reimbursement by faxing it to 001-480-614-7674 or filing it via our
website at www.fepblue.org/myblue.
132 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard and Basic Option Section 5(i)
Non-FEHB Benefits Available to Plan Members
These benefits are not part of the FEHB contract or premium, and you cannot file an FEHB dispute regarding these benefits. Fees paid
for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. In addition, these
services are not eligible for benefits under the FEHB Program. Please do not file a claim for these services. These programs and
materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information, contact us at the
phone number on the back of your ID card or visit our website at www.fepblue.org.
Blue365
®
– The Blue Cross and Blue Shield Service Benefit Plan presents Blue365, a program that provides easy access to premier
health and wellness products and services to help members build a path to live a healthy life. With Blue365, members get access to
over 90 handpicked discounts from leading brands and there is no limit to how many deals a member can redeem. Many deals are
available and new ones are constantly being added, including:
•Fitness – Get the support you need to achieve your fitness goals with deals on wearable devices, apparel, home gym equipment,
virtual workout classes and in-person gym access.
•Healthy Eyes and Ears – Between replacing hearing aids and correcting your vision, caring for your eyes and ears can get expensive
quickly. Blue365 provides up to 60% off hearing aids, discounts on LASIK surgery and more.
•Home and Family – Your home and family can influence your mental, physical, emotional, and financial well-being. Blue365 offers
discounts on premium vitamins and supplements, pet insurance, fertility services, products for new parents, financial offers, family
health and more.
•Nutrition – Blue365 offers a variety of deals that help you eat right. Choose from meal kit subscriptions, chef-prepared entrees,
weight management plans and more.
•Personal Care – A little self-care can go a long way toward improving your mental health. Blue365 offers exclusive discounts on
skin care products, oral care products, tooth-whitening kits, mindfulness subscriptions and much more.
•Travel – Sometimes a vacation is all you need to escape stress and reset. Blue365 makes family getaways more affordable with
discounted access to lodging, car rentals and vacation packages.
Each week, Blue365 members can receive great health and wellness deals via email. With Blue365, there is no paperwork to fill out.
Just visit http://www.fepblue.org/blue365 and select Get Started to learn more about the various Blue365 vendors and discounts. The
Blue Cross and Blue Shield Service Benefit Plan may receive payments from Blue365 vendors. The Plan does not recommend,
endorse, warrant, or guarantee any specific Blue365 vendor or item. Vendors and the program are subject to change at any time.
Discount Drug Program – The Discount Drug Program is available to members not enrolled in the FEP Medicare Prescription Drug
Program at no additional premium cost. It enables you to purchase, at discounted prices, certain prescription drugs that are not
covered by the regular prescription drug benefit. Discounts vary by drug product, but average about 24%. The program permits you to
obtain discounts on several drugs related to dental care, weight loss, hair removal and hair growth, and other miscellaneous health
conditions. Please refer to www.fepblue.org/ddp for a full list of discounted drugs, including those that may be added to this list as
they are approved by the U.S. Food and Drug Administration (U.S. FDA). To use the program, simply present a valid prescription and
your Service Benefit Plan ID card at a Preferred retail pharmacy. The pharmacist will ask you for payment in full at the negotiated
discount rate. For more information, visit www.fepblue.org/ddp or call 800-624-5060.
133 2024 Blue Cross® and Blue Shield® Service Benefit Plan Non-FEHB Benefits Available to Plan Members
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover
The exclusions in this Section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure.
Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically necessary to
prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific
services, such as transplants, see Section 3,
You need prior Plan approval for certain services
.
We do not cover the following:
•Services, drugs, or supplies you receive while you are not enrolled in this Plan.
•Services, drugs, or supplies that are not medically necessary.
•Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice in the United
States.
•Services, drugs, or supplies billed by Preferred and Member facilities for inpatient care related to specific medical errors and
hospital-acquired conditions known as Never Events.
•Experimental or investigational procedures, treatments, drugs, or devices (see Section 5(b) regarding transplants).
•Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to
term, or when the pregnancy is the result of an act of rape or incest.
•Services, drugs, or supplies related to sexual dysfunction or sexual inadequacy (except for surgical placement of penile prostheses
to treat erectile dysfunction and gender affirming surgeries specifically listed as covered).
•Travel expenses except as specifically provided for covered transplants performed in a Blue Distinction Center for Transplant (see
Section 5(b)).
•Services, drugs, or supplies you receive from a provider or facility barred or suspended from the FEHB Program.
•Services, drugs, or supplies you receive in a country sanctioned by the Office of Foreign Assets Control (OFAC) of the U.S.
Department of the Treasury, from a provider or facility not appropriately licensed to deliver care in that country.
•Services or supplies for which no charge would be made if the covered individual had no health insurance coverage.
•Services, drugs, or supplies you receive without charge while in active military service.
•Charges which the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not
covered by Medicare Parts A and/or B, doctor’s charges exceeding the amount specified by the Department of Health & Human
Services when benefits are payable under Medicare, or state premium taxes however applied. See Section 9.
•Prescriptions, services or supplies ordered, performed, or furnished by you or your immediate relatives or household members, such
as spouse, parents, children, brothers, or sisters by blood, marriage, or adoption.
•Services or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs; oxygen; and
physical, speech, and occupational therapy provided by a qualified professional therapist on an outpatient basis are covered subject
to Plan limits.
•Services, drugs, or supplies you receive from noncovered providers.
•Services, drugs, or supplies you receive for cosmetic purposes.
•Services or supplies for the treatment of obesity, weight reduction, or dietary control, except for office visits, diagnostic tests, prior
approved weight loss drugs covered under the pharmacy program, and procedures and services for the treatment of severe obesity
listed in Section 5(b).
•Services you receive from a provider that are outside the scope of the provider’s licensure or certification.
•Any dental or oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or
preparing the mouth for the fitting or continued use of dentures, except as specifically described in Section 5(g),
Dental Benefits
,
and Section 5(b) under
Oral and Maxillofacial Surgery
.
•Orthodontic care for malposition of the bones of the jaw or for temporomandibular joint (TMJ) syndrome.
•Services of standby physicians.
134 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 6
•Self-care or self-help training.
•Custodial or long-term care (see
Definitions
).
•Personal comfort items such as beauty and barber services, radio, television, or phone.
•Furniture (other than medically necessary durable medical equipment) such as commercial beds, mattresses, chairs.
•Routine services, such as periodic physical examinations; screening examinations; immunizations; and services or tests not related
to a specific diagnosis, illness, injury, set of symptoms, or maternity care, except for those preventive services specifically covered
under
Preventive Care, Adult
and
Preventive Care, Child
in Sections 5(a) and 5(c); and certain routine services associated with
covered clinical trials (see Section 9).
•Recreational or educational therapy, and any related diagnostic testing, except as provided by a hospital during a covered inpatient
stay.
•Applied behavior analysis (ABA) and related services for any condition other than an autism spectrum disorder.
•Applied behavior analysis (ABA) services and related services performed as part of an educational program; or provided in or by a
school/educational setting; or provided as a replacement for services that are the responsibility of the educational system.
•Topical Hyperbaric Oxygen Therapy (THBO).
•Research costs (costs related to conducting a clinical trial such as research physician and nurse time, analysis of results, and clinical
tests performed only for research purposes).
•Professional charges for after-hours care, except when associated with services provided in a physician's office.
•Incontinence products such as incontinence garments (including adult or infant diapers, briefs, and underwear), incontinence pads/
liners, bed pads, or disposable washcloths.
•Alternative medicine services including, but not limited to, botanical medicine, aromatherapy, herbal/nutritional supplements,
meditation techniques, relaxation techniques, movement therapies, and energy therapies.
•Services, drugs, or supplies related to medical marijuana.
•Advanced care planning, except when provided as part of a covered hospice care treatment plan (see Section 5(c)).
•Membership or concierge service fees charged by a healthcare provider.
•Fees associated with copies, forwarding or mailing of records except as specifically described in Section 8.
•Services not specifically listed as covered.
•Services or supplies we are prohibited from covering under the Federal Law.
135 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 6
Section 7. Filing a Claim for Covered Services
This Section primarily deals with post-service claims (claims for services, drugs, or supplies you have already received).
See Section 3 for information on pre-service claims procedures (services, drugs, or supplies requiring precertification or prior
approval), including urgent care claims procedures.
To obtain claim forms or other claims filing advice, or answers to your questions about our
benefits, contact us at the customer service phone number on the back of your Service Benefit
Plan ID card, or at our website at www.fepblue.org.
In most cases, physicians and facilities file claims for you. Just present your Service Benefit Plan
ID card when you receive services. Your provider must file on the CMS-1500, Health Insurance
Claim Form. Your facility will file on the UB-04 form.
When you must file a claim – such as when another group health Plan is primary – submit it on
the CMS-1500 or a claim form that includes the information shown below. Use a separate claim
form for each family member. For long or continuing inpatient stays, or other long-term care, you
should submit claims at least every 30 days. Bills and receipts should be itemized and show:
• Patient’s name, date of birth, address, phone number, and relationship to enrollee
• Patient’s Plan identification number
• Name and address of person or company providing the service or supply
• Dates that services or supplies were furnished
• Diagnosis
• Type of each service or supply
• Charge for each service or supply
Note: Canceled checks, cash register receipts, balance due statements, or bills you prepare
yourself are not acceptable substitutes for itemized bills.
In addition:
• If another health plan is your primary payor, you must send a copy of the explanation of
benefits (EOB) form you received from your primary payor (such as the Medicare Summary
Notice (MSN)) with your claim.
• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
• If your claim is for the rental or purchase of durable medical equipment, home nursing care, or
physical, occupational, speech, or cognitive rehabilitation therapy, you must provide a written
statement from the provider specifying the medical necessity for the service or supply and the
length of time needed.
• Claims for dental care to repair accidental injury to sound natural teeth should include
documentation of the condition of your teeth before the accidental injury, documentation of
the injury from your provider(s), and a treatment plan for your dental care. We may request
updated treatment plans as your treatment progresses.
• Claims for prescription drugs and supplies that are not received from the Retail Pharmacy
Program, through the Mail Service Prescription Drug Program, or through the Specialty
Drug Pharmacy Program must include receipts that show the prescription number, name of
drug or supply, prescribing provider’s name, date, and charge. (See Section 7 for information
on how to obtain benefits from the Retail Pharmacy Program, the Mail Service Prescription
Drug Program, and the Specialty Drug Pharmacy Program.)
How to claim benefits
We will notify you of our decision within 30 days after we receive your post-service claim. If
matters beyond our control require an extension of time, we may take up to an additional 15 days
for review and we will notify you before the expiration of the original 30-day period. Our notice
will include the circumstances underlying the request for the extension and the date when a
decision is expected.
Post-service claims
procedures
136 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 7
If we need an extension because we have not received necessary information (e.g., medical
records) from you, our notice will describe the specific information required and we will allow
you up to 60 days from the receipt of the notice to provide the information.
If you do not agree with our initial decision, you may ask us to review it by following the disputed
claims process detailed in Section 8 of this brochure.
Preferred Retail Pharmacies – When you use Preferred retail pharmacies, show your Service
Benefit Plan ID card. To find a Preferred retail pharmacy, visit www.fepblue.org/provider. If you
use a Preferred retail pharmacy that offers online ordering, have your ID card ready to complete
your purchase. Preferred retail pharmacies file your claims for you. We reimburse them for your
covered drugs and supplies. You pay the applicable coinsurance or copayment.
Note: Even if you use Preferred retail pharmacies, you will have to file a paper claim form to
obtain reimbursement if:
• You do not have a valid Service Benefit Plan ID card;
• You do not use your valid Service Benefit Plan ID card at the time of purchase; or
• You did not obtain prior approval when required (see Section 3).
See the following paragraphs for claim filing instructions.
Non-preferred Retail Pharmacies
Standard Option: You must file a paper claim for any covered drugs or supplies you purchase at
Non-preferred retail pharmacies. Contact your Local Plan or call 800-624-5060 to request a retail
prescription drug claim form to claim benefits. Hearing-impaired members with TTY equipment
may call 711. Follow the instructions on the prescription drug claim form and submit the
completed form to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.
O. Box 52057, Phoenix, AZ 85072-2057.
Basic Option: There are no benefits for drugs or supplies purchased at Non-preferred retail
pharmacies.
Mail Service Prescription Drug Program
Eligible members: We will send you information on our Mail Service Prescription Drug Program,
including an initial mail order form. To use this program:
1. Complete the initial mail order form;
2. Enclose your prescription and copayment;
3. Mail your order to CVS Caremark, P.O. Box 1590, Pittsburgh, PA 15230-1590; and
4. Allow up to two weeks for delivery.
Alternatively, your physician may call in your initial prescription at 800-262-7890, TTY: 711. You
are responsible for the copayment. You are also responsible for the copayments for refills ordered
by your physician.
After that, to order refills either call the same phone number or access our website at www.
fepblue.org and either charge your copayment to your credit card or have it billed to you later.
Allow up to ten days for delivery on refills.
Note: Specialty drugs will not be dispensed through the Mail Service Prescription Drug Program.
See Section 5(f) for information about the Specialty Drug Pharmacy Program.
Basic Option: The Mail Service Prescription Drug Program is available only to members with
primary Medicare Part B coverage under Basic Option.
Prescription drug claims
137 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 7
Specialty Drug Pharmacy Program
Standard and Basic Options: If your physician prescribes a specialty drug that appears on our
Service Benefit Plan Specialty Drug List, your physician may order the initial prescription by
calling our Specialty Drug Pharmacy Program at 888-346-3731, TTY: 711, or you may send your
prescription to: BCBS FEP Specialty Drug Pharmacy Program, CVS Specialty, 9310 Southpark
Center Loop, Orlando, FL 32819. You will be billed later for the copayment. The Specialty Drug
Pharmacy Program will work with you to arrange a delivery time and location that are most
convenient for you. To order refills, call the same phone number to arrange your delivery. You
may either charge your copayment to your credit card or have it billed to you later.
Note: For the most up-to-date listing of covered specialty drugs, call the Specialty Drug Pharmacy
Program at 888-346-3731, TTY: 711, or visit our website, www.fepblue.org.
Keep a separate record of the medical expenses of each covered family member, because
deductibles (under Standard Option) and benefit maximums (such as those for outpatient physical
therapy or preventive dental care) apply separately to each person. Save copies of all medical bills,
including those you accumulate to satisfy a deductible under Standard Option. In most instances
they will serve as evidence of your claim. We will not provide duplicate or year-end statements.
Records
Send us your claim and appropriate documentation as soon as possible. You must submit the claim
by December 31 of the following year after you received the service, unless timely filing was
prevented by administrative operations of Government or legal incapacity, provided you submitted
the claim as soon as reasonably possible. If we return a claim or part of a claim for additional
information (e.g., diagnosis codes, dates of service, etc.), you must resubmit it within 90 days, or
before the timely filing period expires, whichever is later.
Note: Timely filing for overseas pharmacy claims is limited to one year from the prescription fill
date.
Note: Once we pay benefits, there is a five-year limitation on the reissuance of uncashed checks.
Deadline for filing your
claim
Please refer to the claims filing information in Section 5(i). Overseas claims
Please reply promptly when we ask for additional information. We may delay processing or deny
benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed
while we await all of the additional information needed to process your claim.
When we need more
information
You may designate an authorized representative to act on your behalf for filing a claim or to
appeal claims decisions to us. For urgent care claims, a healthcare professional with knowledge of
your medical condition will be permitted to act as your authorized representative without your
express consent. For the purposes of this Section, we are also referring to your authorized
representative when we refer to you.
Authorized representative
The Secretary of Health and Human Services has identified counties where at least 10% of the
population is literate only in certain non-English languages. The non-English languages meeting
this threshold in certain counties are Spanish, Chinese, Navajo, and Tagalog. If you live in one of
these counties, we will provide language assistance in the applicable non-English language. You
can request a copy of your explanation of benefits (EOB) statement, related correspondence, oral
language services (such as phone customer assistance), and help with filing claims and appeals
(including external reviews) in the applicable non-English language. The English versions of your
EOBs and related correspondence will include information in the non-English language about how
to access language services in that non-English language.
Any notice of an adverse benefit determination or correspondence from us confirming an adverse
benefit determination will include information sufficient to identify the claim involved (including
the date of service, the healthcare provider, and the claim amount, if applicable), and a statement
describing the availability, upon request, of the diagnosis code and its corresponding meaning, and
the procedure or treatment code and its corresponding meaning.
Notice requirements
138 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 7
Section 8. The Disputed Claims Process
Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your
post-service claim (a claim where services, drugs, or supplies have already been provided). In Section 3,
If you disagree with our pre-
service claim decision
, we describe the process you need to follow if you have a claim for services, drugs, or supplies that must have
precertification (such as inpatient hospital admissions) or prior approval from the Plan.
You may appeal directly to the U.S. Office of Personnel Management (OPM) if we do not follow required claims processes. For more
information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional
requirements not listed in Sections 3, 7, and 8 of this brochure, please call your Plan’s customer service representative at the phone
number found on your enrollment card, our brochure, or our website ( www.fepblue.org).
To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan
documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your
request, please call us at the customer service phone number on the back of your Service Benefit Plan ID card, or send your request to
us at the address shown on your explanation of benefits (EOB) form for the Local Plan that processed the claim (or, for Prescription
drug benefits, our Retail Pharmacy Program, Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program).
Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the
claim, without regard to whether such information was submitted or considered in the initial benefit determination.
When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational),
we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the
medical judgment and who was not involved in making the initial decision.
Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their
subordinate, who made the initial decision.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any
individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of
benefits.
Step Description
Ask us in writing to reconsider our initial decision. You must:
a) Write to us within 6 months from the date of our decision; and
b) Send your request to us at the address shown on your explanation of benefits (EOB) form for the Local Plan that
processed the claim (or, for Prescription drug benefits, our Retail Pharmacy Program, Mail Service Prescription Drug
Program, or the Specialty Drug Pharmacy Program); and
c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this
brochure; and
d) Include copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms.
We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon,
or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will
provide you with this information sufficiently in advance of the date that we are required to provide you with our
reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to
provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our
decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in
Step 3.
1
In the case of a post-service claim, we have 30 days from the date we receive your request to:
a) Pay the claim or
b) Write to you and maintain our denial or
2
139 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 8
c) Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request. We will then decide
within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We
will base our decision on the information we already have. We will write to you with our decision.
If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us – if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information – if we did not send you a decision within 30 days after we received
the additional information.
Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance
Operations, FEHB 1, 1900 E Street NW, Washington, DC 20415-3610.
Send OPM the following information:
• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical records, and
explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim;
• Your daytime phone number and the best time to call; and
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email
address, you may receive OPM’s decision more quickly.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative,
such as medical providers, must include a copy of your specific written consent with the review request. However, for
urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized
representative without your express consent.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons
beyond your control.
3
OPM will review your disputed claim request and will use the information it collects from you and us to decide whether
our decision is correct. OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service. OPM will send you a final decision or notify you of the status of OPM's review within 60 days.
There are no other administrative appeals.
If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services,
drugs, or supplies, or from the year in which you were denied precertification or prior approval. This is the only deadline
that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claims decision. This
information will become part of the court record.
You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your
lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when
OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.
4
140 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 8
Note: If you have a serious or life-threatening condition (one that may cause permanent loss of bodily functions or death if not treated
as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at the customer service phone
number on the back of your Service Benefit Plan ID card. We will expedite our review (if we have not yet responded to your claim);
or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s FEHB 1 at 202-606-0727 between 8 a.
m. and 5 p.m. Eastern Time.
Please remember that we do not make decisions about Plan eligibility issues. For example, we do not determine whether you or a
family member is covered under this Plan. You must raise eligibility issues with your agency personnel/payroll office if you are an
employee, your retirement system if you are an annuitant, or the Office of Workers’ Compensation Programs if you are receiving
Workers’ Compensation benefits.
141 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 8
Section 9. Coordinating Benefits With Medicare and Other Coverage
You must tell us if you or a covered family member has coverage under any other
group health plan or has automobile insurance that pays healthcare expenses
without regard to fault. This is called “double coverage.”
When you have double coverage, one plan normally pays its benefits in full as the
primary payor and the other plan pays a reduced benefit as the secondary payor. We,
like other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners’ (NAIC) guidelines. For example:
• If you are covered under our Plan as a dependent, any group health insurance you have
from your employer will pay primary and we will pay secondary.
• If you are an annuitant under our Plan and also are actively employed, any group
health insurance you have from your employer will pay primary and we will pay
secondary.
• When you are entitled to the payment of healthcare expenses under automobile
insurance, including no-fault insurance and other insurance that pays without regard to
fault, your automobile insurance is the primary payor and we are the secondary payor.
For more information on NAIC rules regarding the coordinating of benefits, visit our
website at www.fepblue.org/coordinationofbenefits.
When we are the primary payor, we will pay the benefits described in this brochure.
When we are the secondary payor, we will determine our allowance. After the primary
plan processes the benefit, we will pay what is left of our allowance, up to our regular
benefit. We will not pay more than our allowance. For example, we will generally only
make up the difference between the primary payor’s benefits payment and 100% of the
Plan allowance, subject to our applicable deductible (under Standard Option) and
coinsurance or copayment amounts, except when Medicare is the primary payor
(described later in this section). Thus, it is possible that the combined payments from both
plans may not equal the entire amount billed by the provider.
Note: When we pay secondary to primary coverage you have from a prepaid plan (HMO),
we base our benefits on your out-of-pocket liability under the prepaid plan (generally, the
prepaid plan’s copayments), subject to our deductible (under Standard Option) and
coinsurance or copayment amounts.
In certain circumstances when we are secondary and there is no adverse effect on you
(that is, you do not pay any more), we may also take advantage of any provider discount
arrangements your primary plan may have and only make up the difference between the
primary plan’s payment and the amount the provider has agreed to accept as payment in
full from the primary plan.
Note: Any visit limitations that apply to your care under this plan are still in effect when
we are the secondary payor.
Remember: Even if you do not file a claim with your other plan, you must still tell us that
you have double coverage, and you must also send us documents about your other
coverage if we ask for them.
Please see Section 4,
Your Costs for Covered Services
, for more information about
how we pay claims.
When you have other health
coverage
TRICARE is the healthcare program for eligible dependents of military persons, and
retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If TRICARE
or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA
Health Benefits Advisor if you have questions about these programs.
• TRICARE and CHAMPVA
142 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any
applicable Plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement or employing office. If you later want to re-enroll in the FEHB
Program, generally you may do so only at the next Open Season unless you involuntarily
lose coverage under TRICARE or CHAMPVA.
Every job-related injury or illness should be reported as soon as possible to your
supervisor. Injury also means any illness or disease that is caused or aggravated by the
employment as well as damage to medical braces, artificial limbs and other prosthetic
devices. If you are a federal or postal employee, ask your supervisor to authorize medical
treatment by use of form CA-16 before you obtain treatment. If your medical treatment is
accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider
will be compensated by OWCP. If your treatment is determined not job-related, we will
process your benefit according to the terms of this plan, including use of in-network
providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send
it to your provider as soon as possible after treatment, to avoid complications about
whether your treatment is covered by this plan or by OWCP.
We do not cover services that:
• You (or a covered family member) need because of a workplace-related illness or
injury that the Office of Workers’ Compensation Programs (OWCP) or a similar
federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws.
Once OWCP or a similar agency pays its maximum benefits for your treatment, we will
cover your care.
• Workers’ Compensation
When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored
program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in one of these state programs, eliminating your
FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement or employing office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the state program.
• Medicaid
We do not cover services and supplies when a local, state, or federal government agency
directly or indirectly pays for them.
When other Government agencies
are responsible for your care
If another person or entity, through an act or omission, causes you to suffer an injury or
illness, and if we paid benefits for that injury or illness, you must agree to the provisions
listed below. In addition, if you are injured and no other person or entity is responsible but
you receive (or are entitled to) a recovery from another source, and if we paid benefits for
that injury, you must agree to the following provisions:
• All recoveries you or your representatives obtain (whether by lawsuit, settlement,
insurance or benefit program claims, or otherwise), no matter how described or
designated, must be used to reimburse us in full for benefits we paid. Our share of any
recovery extends only to the amount of benefits we have paid or will pay to you, your
representatives, and/or healthcare providers on your behalf. For purposes of this
provision, “you” includes your covered dependents, and “your representatives”
include, if applicable, your heirs, administrators, legal representatives, parents (if you
are a minor), successors, or assignees. This is our right of recovery.
When others are responsible for
injuries
143 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
• We are entitled under our right of recovery to be reimbursed for our benefit payments
even if you are not “made whole” for all of your damages in the recoveries that you
receive. Our right of recovery is not subject to reduction for attorney’s fees and costs
under the “common fund” or any other doctrine.
• We will not reduce our share of any recovery unless, in the exercise of our discretion,
we agree in writing to a reduction (1) because you do not receive the full amount of
damages that you claimed or (2) because you had to pay attorneys’ fees.
• You must cooperate in doing what is reasonably necessary to assist us with our right of
recovery. You must not take any action that may prejudice our right of recovery.
• If you do not seek damages for your illness or injury, you must permit us to initiate
recovery on your behalf (including the right to bring suit in your name). This is called
subrogation.
If you do seek damages for your illness or injury, you must tell us promptly that you have
made a claim against another party for a condition that we have paid or may pay benefits
for, you must seek recovery of our benefit payments and liabilities, and you must tell us
about any recoveries you obtain, whether in or out of court. We may seek a first priority
lien on the proceeds of your claim in order to reimburse ourselves to the full amount of
benefits we have paid or will pay.
We may request that you sign a reimbursement agreement and/or assign to us (1) your
right to bring an action or (2) your right to the proceeds of a claim for your illness or
injury. We may delay processing of your claims until you provide the signed
reimbursement agreement and/or assignment, and we may enforce our right of recovery
by offsetting future benefits.
Note: We will pay the costs of any covered services you receive that are in excess of any
recoveries made.
Our rights of recovery and subrogation as described in this Section may be enforced, at
the Carrier’s option, by the Carrier, by any of the Local Plans that administered the
benefits paid in connection with the injury or illness at issue, or by any combination of
these entities. Please be aware that more than one Local Plan may have a right of
recovery/subrogation for claims arising from a single incident (e.g., a car accident
resulting in claims paid by multiple Local Plans) and that the resolution by one Local Plan
of its lien will not eliminate another Local Plan’s right of recovery.
Among the other situations covered by this provision, the circumstances in which we may
subrogate or assert a right of recovery shall also include:
• When a third party injures you, for example, in an automobile accident or through
medical malpractice;
• When you are injured on premises owned by a third party; or
• When you are injured and benefits are available to you or your dependent, under any
law or under any type of insurance, including, but not limited to:
- No-fault insurance and other insurance that pays without regard to fault, including
personal injury protection benefits, regardless of any election made by you to treat
those benefits as secondary to this Plan
- Uninsured and underinsured motorist coverage
- Workers’ Compensation benefits
- Medical reimbursement coverage
Contact us if you need more information about subrogation.
144 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
Some FEHB plans already cover some dental and vision services. When you are covered
by more than one dental/vision plan, coverage provided under your FEHB plan remains as
your primary coverage. FEDVIP coverage pays secondary to that coverage. When you
enroll in a dental and/or vision plan, you will be asked to provide information on your
FEHB plan so that your plans can coordinate benefits. Providing your FEHB information
may reduce your out-of-pocket cost.
When you have Federal
Employees Dental and Vision
Insurance Plan (FEDVIP)
If you are a participant in an approved clinical trial, this health Plan will provide benefits
for covered related care as follows, if it is not provided by the clinical trial:
• Routine care costs – costs for medically necessary services such as doctor visits, lab
tests, X-rays and scans, and hospitalizations related to treating the patient’s condition,
whether the patient is in a clinical trial or is receiving standard therapy. We provide
benefits for these types of costs at the benefit levels described in Section 5 (
Benefits
)
when the services are covered under the Plan and we determine that they are medically
necessary.
• Extra care costs – costs of covered services related to taking part in a clinical trial
such as additional tests that a patient may need as part of the trial, but not as part of the
patient’s routine care. This Plan covers extra care costs related to taking part in an
approved clinical trial for a covered stem cell transplant such as additional tests that a
patient may need as part of the clinical trial protocol, but not as part of the patient’s
routine care. For more information about approved clinical trials for covered stem cell
transplants, see Section 5(b). Extra care costs related to taking part in any other
type of clinical trial are not covered. We encourage you to contact us at the customer
service phone number on the back of your ID card to discuss specific services if you
participate in a clinical trial.
• Research costs – costs related to conducting the clinical trial such as research
physician and nurse time, analysis of results, and clinical tests performed only for
research purposes. These costs are generally covered by the clinical trials. This Plan
does not cover these costs.
An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial
that is conducted in relation to the prevention, detection, or treatment of cancer or other
life-threatening disease or condition, and is either Federally funded; conducted under an
investigational new drug application reviewed by the Food and Drug Administration (U.S.
FDA); or is a drug trial that is exempt from the requirement of an investigational new drug
application.
Clinical trials
For more detailed information on “What is Medicare?” and “Should I enroll in
Medicare?” please contact Medicare at 1-800-Medicare 800-633-4227, TTY: 711, or at
www.medicare.gov.
When you have Medicare
The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or
hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share.
All physicians and other providers are required by law to file claims directly to Medicare
for members with Medicare Part B, when Medicare is primary. This is true whether or not
they accept Medicare.
When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care. For example, you must continue to
obtain prior approval for some prescription drugs and organ/tissue transplants before we
will pay benefits. However, you do not have to precertify inpatient hospital stays when
Medicare Part A is primary (see Section 3 for exceptions).
Claims process when you have the Original Medicare Plan – You will probably not
need to file a claim form when you have both our Plan and the Original Medicare Plan.
• The Original Medicare Plan
(Part A or Part B)
145 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
When we are the primary payor, we process the claim first.
When the Original Medicare Plan is the primary payor, Medicare processes your claim
first. In most cases, your claim will be coordinated automatically and we will then provide
secondary benefits for the covered charges. To find out if you need to do something to file
your claims, call us at the customer service phone number on the back of your Service
Benefit Plan ID card or visit our website at www.fepblue.org.
We waive some costs if the Original Medicare Plan is your primary payor – We will
waive some out-of-pocket costs as follows:
When Medicare Part A is primary –
• Under Standard Option, we will waive our:
- Inpatient hospital per-admission copayments; and
- Inpatient Member and Non-member hospital coinsurance.
• Under Basic Option, we will waive our:
- Inpatient hospital per-day copayments.
Note: Once you have exhausted your Medicare Part A benefits:
• Under Standard Option, you must then pay any difference between our allowance
and the billed amount at Non-member hospitals.
• Under Basic Option, you must then pay the inpatient hospital per-day copayments.
When Medicare Part B is primary –
• Under Standard Option, we will waive our:
- Calendar year deductible;
- Coinsurance and copayments for inpatient and outpatient services and supplies
provided by physicians and other covered healthcare professionals; and
- Coinsurance for outpatient facility services.
• Under Basic Option, we will waive our:
- Copayments and coinsurance for care received from covered professional and
facility providers.
Note: We do not waive benefit limitations, such as the 25-visit limit for home (skilled)
nursing visits. In addition, we do not waive any coinsurance or copayments for
prescription drugs.
You can find more information about how our Plan coordinates benefits with Medicare in
our
Medicare and You Guide for Federal Employees
available online at www.fepblue.org.
You must tell us if you or a covered family member has Medicare coverage, and let us
obtain information about services denied or paid under Medicare if we ask. You must also
tell us about other coverage you or your covered family members may have, as this
coverage may affect the primary/secondary status of this Plan and Medicare.
• Tell us about your Medicare
coverage
If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract
agreeing that you can be billed directly for services ordinarily covered by Original
Medicare. Should you sign an agreement, Medicare will not pay any portion of the
charges, and we will not increase our payment. We will still limit our payment to the
amount we would have paid after Original Medicare’s payment. You may be responsible
for paying the difference between the billed amount and the amount we paid.
• Private contract with your
physician
146 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
If you are eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from a Medicare Advantage plan. These are private healthcare choices (like
HMOs and regional PPOs) in some areas of the country. To learn more about Medicare
Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), TTY: 711, or at
www.medicare.gov.
If you enroll in a Medicare Advantage plan, the following options are available to you:
This Plan and another plan’s Medicare Advantage plan: You may enroll in another
plan’s Medicare Advantage plan and also remain enrolled in our FEHB Plan. If you enroll
in a Medicare Advantage plan, tell us. We will need to know whether you are in the
Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate
benefits with Medicare.
Under Standard Option, we will still provide benefits when your Medicare Advantage plan
is primary, even out of the Medicare Advantage plan’s network and/or service area.
However, we will not waive any of our copayments, coinsurance, or deductibles, if you
receive services from providers who do not participate in the Medicare Advantage plan.
Under Basic Option, we provide benefits for care received from Preferred providers when
your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s
network and/or service area. However, we will not waive any of our copayments or
coinsurance for services you receive from Preferred providers who do not participate in
the Medicare Advantage plan. Please remember that you must receive care from Preferred
providers in order to receive Basic Option benefits. See Section 3 for the exceptions to
this requirement.
Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your
Medicare Advantage plan premium.) For information on suspending your FEHB
enrollment, contact your retirement or employing office. If you later want to re-enroll in
the FEHB Program, generally you may do so only at the next Open Season unless you
involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.
• Medicare Advantage (Part C)
When we are the primary payor, we process the claim first. If you enroll in Medicare Part
D and we are the secondary payor, we will review claims for your prescription drug costs
that are not covered by Medicare Part D and consider them for payment under the FEHB
plan.
• Medicare prescription drug
coverage (Part D)
This health plan does not coordinate its prescription drug benefits with Medicare Part B. • Medicare prescription drug
coverage (Part B)
147 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates whether
Medicare or this Plan should be the primary payor for you according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these
requirements correctly. (Having coverage under more than two health plans may change the order of benefits determined on
this chart.)
Primary Payor Chart
A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the
individual with Medicare is...
Medicare This Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an
annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from
the FEHB (your employing office will know if this is the case) and you are not covered under
FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded
from the FEHB (your employing office will know if this is the case) and...
• You have FEHB coverage on your own or through your spouse who is also an active
employee
• You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired
under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and
you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status
for Part B
services
for other
services
8) Are a Federal employee receiving Workers' Compensation
*
9) Are a Federal employee receiving disability benefits for six months or more
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and...
• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD
(30-month coordination period)
• It is beyond the 30-month coordination period and you or a family member are still entitled
to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
• This Plan was the primary payor before eligibility due to ESRD (for 30 month
coordination period)
• Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage (TCC) and...
• Medicare based on age and disability
• Medicare based on ESRD (for the 30 month coordination period)
• Medicare based on ESRD (after the 30 month coordination period)
C. When either you or a covered family member are eligible for Medicare solely due to
disability and you...
1) Have FEHB coverage on your own as an active employee or through a family member who
is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an
annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse
*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.
148 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
When you are age 65 or over and do not have Medicare
Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those payments you would be
entitled to if you had Medicare. Your physician and hospital must follow Medicare rules and cannot bill you for more than they could
bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital care and non-physician-based
care are not covered by this law; regular Plan benefits apply. The following chart has more information about the limits.
If you:
•are age 65 or over; and
•do not have Medicare Part A, Part B, or both; and
•have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
•are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)
Then, for your inpatient hospital care:
•The law requires us to base our payment on an amount – the “equivalent Medicare amount” – set by Medicare’s rules for what
Medicare would pay, not on the actual charge.
•You are responsible for your deductible (Standard Option only), coinsurance, or copayments under this Plan.
•You are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation
of benefits (EOB) form that we send you.
•The law prohibits a hospital from collecting more than the equivalent Medicare amount.
And, for your physician care, the law requires us to base our payment and your applicable coinsurance or copayment on:
•an amount set by Medicare and called the “Medicare-approved amount,” or
•the actual charge if it is lower than the Medicare-approved amount.
If your physician: Participates with Medicare or accepts Medicare assignment for the claim and is in our Preferred network
Then you are responsible for:
Standard Option - your deductibles, coinsurance, and copayments.
Basic Option - your copayments and coinsurance.
If your physician: Participates with Medicare or accepts Medicare assignment and is not in our Preferred network
Then you are responsible for:
Standard Option - your deductibles, coinsurance, and copayments, and any balance up to the Medicare-approved amount.
Basic Option - all charges.
If your physician: Does not participate with Medicare and is in our Preferred network
Note: In many cases, your payment will be less because of our Preferred agreements. Contact your Local Plan for information about
what your specific Preferred provider can collect from you.
Then you are responsible for:
Standard Option - your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare-approved
amount.
Basic Option - your copayments and coinsurance, and any balance up to 115% of the Medicare-approved amount.
If your physician: Does not participate with Medicare and is not in our Preferred network
Then you are responsible for:
Standard Option - your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare-approved
amount.
Basic Option - all charges.
149 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
If your physician: Opts-out of Medicare via private contract
Then you are responsible for:
Standard Option - your deductibles, coinsurance, copayments, and any balance your physician charges.
Basic Option - your deductibles, coinsurance, copayments, and any balance your physician charges.
It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect
only up to the Medicare-approved amount.
Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or
hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than
allowed, ask for a refund. If you need further assistance, call us.
A physician may have opted-out of Medicare and may or may not ask you to sign a private
contract agreeing that you can be billed directly for services ordinarily covered by
Original Medicare. This is different than a Non-participating doctor, and we recommend
you ask your physician if they have opted-out of Medicare. Should you visit an opt-out
physician, the physician will not be limited to 115% of the Medicare-approved amount.
You may be responsible for paying the difference between the billed amount and our
regular in-network/out-of-network benefits.
Physicians Who Opt-Out of
Medicare
We limit our payment to an amount that supplements the benefits that Medicare would
pay under Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance),
regardless of whether Medicare pays.
Note: We pay our regular benefits for emergency services to a facility provider, such as a
hospital, that does not participate with Medicare and is not reimbursed by Medicare.
We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice
(MRA) when the MRA statement is submitted to determine our payment for covered
services provided to you if Medicare is primary, when Medicare does not pay the VA
facility.
If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for
services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.
• If your physician accepts Medicare assignment, you pay nothing for covered charges
(see note below for Basic Option).
• If your physician does not accept Medicare assignment, you pay the difference
between the “limiting charge” or the physician’s charge (whichever is less) and our
payment combined with Medicare’s payment (see note below for Basic Option).
Note: Under Basic Option, you must see Preferred providers in order to receive
benefits. See Section 3 for the exceptions to this requirement.
It is important to know that a physician who does not accept Medicare assignment may
not bill you for more than 115% of the amount Medicare bases its payment on, called the
“limiting charge.” The Medicare Summary Notice (MSN) form that you receive from
Medicare will have more information about the limiting charge. If your physician tries to
collect more than allowed by law, ask the physician to reduce the charges. If the physician
does not, report the physician to the Medicare carrier that sent you the MSN form. Call us
if you need further assistance.
When you have the Original
Medicare Plan (Part A, Part B, or
both)
150 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
Please review the following examples illustrating your cost-share liabilities when Medicare is your primary payor and your provider
is in our network and participates with Medicare compared to what you pay without Medicare. Please do not rely on this chart alone
but read all information in this section of the brochure. You can find more information about how our Plan coordinates with Medicare
in our
Medicare and You Guide for Federal Employees
available online at www.fepblue.org.
Benefit Description: Deductible
Standard Option You Pay Without Medicare: $350-Self, $700-Family
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
Standard Option You Pay Without Medicare: $8,000-Self, $16,000-Family
Standard Option You Pay With Medicare Parts A & B: $8,000-Self, $16,000-Family
Basic Option You Pay Without Medicare: $6,500-Self, $13,000-Family
Basic Option With Medicare Parts A & B: $6,500-Self, $13,000-Family
Benefit Description: Part B Premium Reimbursement
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Parts A & B: N/A
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: $800
Benefit Description: Primary Care Provider
Standard Option You Pay Without Medicare: $30
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $35
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Specialist
Standard Option You Pay Without Medicare: $40
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $45
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Inpatient Hospital
Standard Option You Pay Without Medicare: $450
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: $250/day up to $1,500
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Outpatient Hospital
Standard Option You Pay Without Medicare: 15% or $30 copayment
Standard Option You Pay With Medicare Parts A & B: $0.00
Basic Option You Pay Without Medicare: 30% or $35-$500 copayment
Basic Option With Medicare Parts A & B: $0.00
Benefit Description: Incentives Offered
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Parts A & B: N/A
Basic Option You Pay Without Medicare: N/A
Basic Option With Medicare Parts A & B: N/A
151 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 9
Section 10. Definitions of Terms We Use in This Brochure
An injury caused by an external force or element such as a blow or fall that requires immediate medical
attention, including animal bites and poisonings. Note: Injuries to the teeth while eating are not
considered accidental injuries. Dental care for accidental injury is limited to dental treatment necessary
to repair sound natural teeth.
Accidental injury
The period from entry (admission) as an inpatient into a hospital (or other covered facility) until
discharge. In counting days of inpatient care, the date of entry and the date of discharge count as the
same day.
Admission
Receiving information on the types of life-sustaining treatments that are available, completing advance
directives and other standard forms, and/or if you are diagnosed with a terminal illness and making
decisions about the care you would want to receive if you become unable to speak for yourself.
Advanced care
planning
Medications and other substances or products given by mouth, inhaled, placed on you, or injected in you
to diagnose, evaluate, and/or treat your condition. Agents include medications and other substances or
products necessary to perform tests such as bone scans, cardiac stress tests, CT scans, MRIs, PET scans,
lung scans, and X-rays, as well as those injected into the joint.
Agents
An authorization by the enrollee or spouse for us to issue payment of benefits directly to the provider. We
reserve the right to pay you, the enrollee, directly for all covered services. Benefits provided under the
contract are not assignable by the member to any person without express written approval of the Carrier,
and in the absence of such approval, any such assignment shall be void. Your specific written consent for
a designated authorized representative to act on your behalf to request reconsideration of a claim decision
(or, for an urgent care claim, for a representative to act on your behalf without designation) does not
constitute an Assignment. OPM’s contract with us, based on federal statute and regulation, gives you a
right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not
provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any
agreement you enter into with another person or entity (such as a provider, or other individual or entity)
authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf,
does not constitute an Assignment, is not a valid authorization under this contract, and is void.
Please visit www.fepblue.org to obtain a valid authorization form.
Assignment
Reproductive services, testing, and treatments involving manipulation of eggs, sperm, and embryos to
achieve pregnancy. In general, assisted reproductive technology (ART) procedures are used to retrieve
eggs from an ovulating individual, combine them with sperm in the laboratory, and then implant the
embryos or donate them to an individual capable of pregnancy.
Assisted
reproductive
technology (ART)
A complex drug or product that is manufactured in a living organism, or its components, that is used as a
diagnostic, preventive or therapeutic agent.
Biologic drug
A U.S. FDA-approved biologic drug, which is considered highly similar to an original brand-name
biologic drug, with no clinically meaningful differences from the original biologic drug in terms of
safety, purity and potency.
Biosimilar drug
A U.S. FDA-approved biosimilar drug that may be automatically substituted for the original brand-name
biologic drug.
Biosimilar,
interchangeable
drug
January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the
effective date of their enrollment and ends on December 31 of the same year.
Calendar year
The Blue Cross and Blue Shield Association, on behalf of the local Blue Cross and Blue Shield Plans. Carrier
An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is
conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease
or condition, and is either Federally funded; conducted under an investigational new drug application
reviewed by the U.S. Food and Drug Administration (U.S. FDA); or is a drug trial that is exempt from
the requirement of an investigational new drug application.
Clinical trials
152 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
See Section 4. Coinsurance
A claim for continuing care or an ongoing course of treatment that is subject to prior approval. See
Section 3.
Concurrent care
claims
A condition that existed at or from birth and is a significant deviation from the common form or norm.
Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birth marks;
ambiguous genitalia; and webbed fingers and toes. Note: Congenital anomalies do not include conditions
related to the teeth or intra-oral structures supporting the teeth.
Congenital anomaly
See Section 4. Copayment
Any surgical procedure or any portion of a procedure performed primarily to improve physical
appearance through change in bodily form, except for repair of accidental injury, or to restore or correct a
part of the body that has been altered as a result of disease or surgery or to correct a congenital anomaly.
Cosmetic surgery
See Section 4. Cost-sharing
Services we provide benefits for, as described in this brochure. Covered services
Facility-based care that does not require access to the full spectrum of services performed by licensed
healthcare professionals that is available 24 hours a day in acute inpatient hospital settings to avoid
imminent, serious, medical or psychiatric consequences. By “facility-based,” we mean services provided
in a hospital, long-term care facility, extended care facility, skilled nursing facility, residential treatment
center, school, halfway house, group home, or any other facility providing skilled or unskilled treatment
or services to individuals whose conditions have been stabilized. Custodial or long-term care can also be
provided in the patient’s home, however defined.
Custodial or long-term care may include services that a person not medically skilled could perform
safely and reasonably with minimal training, or that mainly assist the patient with daily living activities,
such as:
1. Personal care, including help in walking, getting in and out of bed, bathing, eating (by spoon, tube, or
gastrostomy), exercising, or dressing;
2. Homemaking, such as preparing meals or special diets;
3. Moving the patient;
4. Acting as companion or sitter;
5. Supervising medication that can usually be self-administered; or
6. Treatment or services that any person can perform with minimal instruction, such as recording pulse,
temperature, and respiration; or administration and monitoring of feeding systems.
We do not provide benefits for custodial or long-term care, regardless of who recommends the care or
where it is provided. The Carrier, its medical staff, and/or an independent medical review determine
which services are custodial or long-term care.
Custodial or long-
term care
Equipment and supplies that are:
1. Prescribed by your physician (i.e., the physician who is treating your illness or injury);
2. Medically necessary;
3. Primarily and customarily used only for a medical purpose;
4. Generally useful only to a person with an illness or injury;
5. Designed for prolonged use; and
6. Used to serve a specific therapeutic purpose in the treatment of an illness or injury.
Durable medical
equipment
Experimental or investigational shall mean:
1. A drug, device, or biological product that cannot be lawfully marketed without approval of the U.S.
Food and Drug Administration (U.S. FDA); and approval for marketing has not been given at the
time it is furnished; or
Experimental or
investigational
services
153 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
2. Reliable evidence shows that the healthcare service (e.g., procedure, treatment, supply, device,
equipment, drug, biological product) is the subject of ongoing phase I, II, or III clinical trials or under
study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as
compared with the standard means of treatment or diagnosis; or
3. Reliable evidence shows that the consensus of opinion among experts regarding the healthcare
service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) is that further
studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety,
its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
4. Reliable evidence shows that the healthcare service (e.g., procedure, treatment, supply, device,
equipment, drug, biological product) does not improve net health outcome, is not as beneficial as any
established alternatives, or does not produce improvement outside of the research setting.
Reliable evidence shall mean only evidence published in peer-reviewed medical literature generally
recognized by the relevant medical community and physician specialty society recommendations, such
as:
1. Published reports and articles in the authoritative medical and scientific literature;
2. The written protocol or protocols used by the treating facility or the protocol(s) of another facility
studying substantially the same drug, device, or biological product or medical treatment or
procedure; or
3. The written informed consent used by the treating facility or by another facility studying substantially
the same drug, device, or biological product or medical treatment or procedure.
A generic alternative is a U.S. FDA-approved generic drug in the same class or group of drugs as your
brand-name drug. The therapeutic effect and safety profile of a generic alternative are similar to your
brand-name drug, but it has a different active ingredient.
Generic alternative
A generic equivalent is a drug whose active ingredients are identical in chemical composition to those of
its brand-name counterpart. Inactive ingredients may not be the same. A generic drug is considered
“equivalent,” if it has been approved by the U.S. FDA as interchangeable with your brand-name drug.
Generic equivalent
Healthcare coverage that you are eligible for based on your employment, or your membership in or
connection with a particular organization or group, that provides payment for medical services or
supplies, or that pays a specific amount of more than $200 per day for hospitalization (including
extension of any of these benefits through COBRA).
Group health
coverage
A physician or other healthcare professional licensed, accredited, or certified to perform specified health
services consistent with state law. See Section 3 for information about how we determine which
healthcare professionals are covered under this Plan.
Healthcare
professional
A questionnaire designed to assess your overall health and identify potential health risks. Service Benefit
Plan members have access to the Blue Cross and Blue Shield HRA (called the “Blue Health
Assessment”) which is supported by a computerized program that analyzes your health and lifestyle
information and provides you with a personal and confidential health action plan that is protected by
HIPAA privacy and security provisions. Results from the Blue Health Assessment include practical
suggestions for making healthy changes and important health information you may want to discuss with
your healthcare provider. For more information, visit our website, www.fepblue.org.
Health Risk
Assessment (HRA)
Infertility caused by a medically necessary medical or surgical intervention used to treat a condition or
disease.
Iatrogenic infertility
A disease or condition characterized by the failure to establish a pregnancy or to carry a pregnancy to
live birth after regular, unprotected sexual intercourse, or a person’s inability to reproduce either as a
single individual or with their partner without medical intervention, or a licensed physician’s findings
based on a patient’s medical, sexual, and reproductive history, age, and/or diagnostic testing.
Infertility
You are an inpatient when you are formally admitted to a hospital with a doctor’s order.
Note: Inpatient care requires precertification. For some services and procedures prior approval must also
be obtained. See Section 3.
Inpatient
154 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
A comprehensive, structured outpatient treatment program that includes extended periods of individual
or group therapy sessions designed to assist members with mental health and/or substance use disorders.
It is an intermediate setting between traditional outpatient therapy and partial hospitalization, typically
performed in an outpatient facility or outpatient professional office setting. Program sessions may occur
more than one day per week. Timeframes and frequency will vary based upon diagnosis and severity of
illness.
Intensive outpatient
care
A Blue Cross and/or Blue Shield Plan that serves a specific geographic area. Local Plan
The term medical food, as defined in Section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) is “a
food which is formulated to be consumed or administered enterally under the supervision of a physician
and which is intended for the specific dietary management of a disease or condition for which distinctive
nutritional requirements, based on recognized scientific principles, are established by medical
evaluation.” In general, to be considered a medical food, a product must, at a minimum, meet the
following criteria: the product must be a food for oral or tube feeding; the product must be labeled for the
dietary management of a specific medical disorder, disease, or condition for which there are distinctive
nutritional requirements; and the product must be intended to be used under medical supervision.
Medical foods
All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable
only when we determine that the criteria for medical necessity are met. Medical necessity shall mean
healthcare services that a physician, hospital, or other covered professional or facility provider,
exercising prudent clinical judgment, would provide to a patient for the purpose of preventing,
evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice in the United States; and
2. Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective
for the patient’s illness, injury, disease, or its symptoms; and
3. Not primarily for the convenience of the patient, physician, or other healthcare provider, and not
more costly than an alternative service or sequence of services at least as likely to produce equivalent
therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury, or
disease, or its symptoms; and
4. Not part of or associated with scholastic education or vocational training of the patient; and
5. In the case of inpatient care, able to be provided safely only in the inpatient setting.
For these purposes, “generally accepted standards of medical practice” means standards that are based on
credible scientific evidence published in peer-reviewed medical literature generally recognized by the
relevant medical community and physician specialty society recommendations.
The fact that one of our covered physicians, hospitals, or other professional or facility providers
has prescribed, recommended, or approved a service or supply does not, in itself, make it medically
necessary or covered under this Plan.
Medical necessity
Under the telehealth benefit you have on-demand access to care for common, non-emergent conditions.
Examples of common conditions include sinus problems, rashes, allergies, cold and flu symptoms, etc.
Minor acute
conditions
Errors in medical care that are clearly identifiable, preventable, and serious in their consequences, such
as surgery performed on a wrong body part, and specific conditions that are acquired during your
hospital stay, such as severe bed sores.
Never Events
Although you may stay overnight in a hospital room and receive meals and other hospital services, some
services and overnight stays – including “observation services” – are actually outpatient care.
Observation care includes care provided to members who require significant treatment or monitoring
before a physician can decide whether to admit them on an inpatient basis, or discharge them to home.
The provider may need 6 to 24 hours or more to make that decision.
If you are in the hospital more than a few hours, always ask your physician or the hospital staff if your
stay is considered inpatient or outpatient.
Observation
services
155 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
You are an outpatient if you are getting emergency department services, observation services, outpatient
surgery, lab tests, X-rays, or any other hospital services, and the doctor has not written an order to admit
you to a hospital as an inpatient. In these cases, you are an outpatient even if you are admitted to a room
in the hospital for observation and spend the night at the hospital.
Outpatient
Our Plan allowance is the amount we use to determine our payment and your cost-share for covered
services. Fee-for-service plans determine their allowances in different ways. If the amount your provider
bills for covered services is less than our allowance, we base your share (coinsurance, deductible, and/or
copayments), on the billed amount. We determine our allowance as follows:
• PPO providers – Our allowance (which we may refer to as the “PPA” for “Preferred Provider
Allowance”) is the negotiated amount that Preferred providers (hospitals and other facilities,
physicians, and other covered healthcare professionals that contract with each local Blue Cross and
Blue Shield Plan, and retail pharmacies that contract with CVS Caremark) have agreed to accept as
payment in full, when we pay primary benefits.
Our PPO allowance includes any known discounts that can be accurately calculated at the time your
claim is processed. For PPO facilities, we sometimes refer to our allowance as the “Preferred rate.”
The Preferred rate may be subject to a periodic adjustment after your claim is processed that may
decrease or increase the amount of our payment that is due to the facility. However, your cost-sharing
(if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to
the reserves of this Plan. If our payment amount is increased, we pay that cost on your behalf. (See
Section 5(g) for special information about limits on the amounts Preferred dentists can charge you
under Standard Option.)
• Participating providers– Our allowance (which we may refer to as the “PAR” for “Participating
Provider Allowance”) is the negotiated amount that these providers (hospitals and other facilities,
physicians, and other covered healthcare professionals that contract with some local Blue Cross and
Blue Shield Plans) have agreed to accept as payment in full, when we pay primary benefits. For
facilities, we sometimes refer to our allowance as the “Member rate.” The Member rate includes any
known discounts that can be accurately calculated at the time your claim is processed, and may be
subject to a periodic adjustment after your claim is processed that may decrease or increase the
amount of our payment that is due to the facility. However, your cost-sharing (if any) does not
change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of
this Plan. If our payment amount is increased, we pay that cost on your behalf.
• Non-participating providers – We have no agreements with these providers to limit what they can
bill you for their services. This means that using Non-participating providers could result in your
having to pay significantly greater amounts for the services you receive. We determine our allowance
as follows:
- For inpatient services at hospitals, and other facilities that do not contract with your local Blue
Cross and Blue Shield Plan (“Non-member facilities”), our allowance is based on the Local Plan
Allowance. The Local Plan Allowance varies by region and is determined by each Plan. If you
would like additional information, or to obtain the current allowed amount, please call the
customer service phone number on the back of your ID card. For inpatient stays resulting from
medical emergencies or accidental injuries, or for emergency deliveries, our allowance is the lesser
of the billed amount or the qualifying payment amount (QPA) determined in accordance with
federal laws and regulations;
- For outpatient, non-emergency services at hospitals and other facilities that do not contract with
your local Blue Cross and Blue Shield Plan (“Non-member facilities”), our allowance is the Local
Plan Allowance. This allowance applies to all of the covered services billed by the hospital. If you
plan on using a Non-member hospital, or other Non-member facility, for your outpatient
procedure, please call us before you receive services at the customer service phone number on the
back of your ID card to obtain the current allowed amount and assistance in estimating your total
out-of-pocket expenses;
Plan allowance
156 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
- For outpatient dialysis services performed or billed by hospitals and other facilities that do not
contract with the local Blue Cross and Blue Shield Plan (“Non-member facilities”), our allowance
is the Local Plan allowance in the geographic area in which the care was performed or obtained.
This allowance applies to the covered dialysis services billed by the hospital or facility. Contact
your Local Plan if you need more information.
Please keep in mind that Non-member facilities may bill you for any difference between the
allowance and the billed amount. You may be able to reduce your out-of-pocket expenses by using
a Preferred hospital for your outpatient surgical procedure or dialysis. To locate a Preferred
provider, visit www.fepblue.org/provider to use our National Doctor and Hospital Finder, or call us
at the customer service phone number on the back of your ID card;
- For outpatient services resulting from a medical emergency or accidental injury that are billed by
Non-member facilities, our allowance is the lesser of the billed amount or the qualifying payment
amount (QPA) determined in accordance with federal laws and regulations (minus any amount for
noncovered services);
- For non-emergency medical services performed in Preferred hospitals provided by physicians and
other covered healthcare professionals identified under the NSA (see Section 4) that do not
contract with your local Blue Cross and Blue Shield Plan and cannot balance bill you under this
regulation, our allowance is equal to the lesser of the billed amount or the qualifying payment
amount (QPA) determined in accordance with federal laws and regulations;
- For physicians and other covered healthcare professionals that do not contract with your local Blue
Cross and Blue Shield Plan, our allowance is equal to the greater of (1) the Medicare participating
fee schedule amount or the Medicare Part B Drug Average Sale Price (ASP) for the service, drug,
or supply in the geographic area in which it was performed or obtained or (2) 100% of the Local
Plan Allowance. In the absence of a Medicare participating fee schedule amount or ASP for any
service, drug, or supply, our allowance is the Local Plan Allowance. Contact your Local Plan if
you need more information. We may refer to our allowance for Non-participating providers as the
“NPA” (for “Non-participating Provider Allowance”);
- For emergency medical services performed in the emergency department of a hospital provided by
physicians and other covered healthcare professionals, and air ambulance providers that do not
contract with your local Blue Cross and Blue Shield Plan, our allowance is the lesser of the billed
amount or the qualifying payment amount (QPA) determined in accordance with federal laws and
regulations;
- For prescription drugs furnished by retail pharmacies that do not contract with CVS Caremark, our
allowance is the average wholesale price (AWP) of a drug on the date it is dispensed, as set forth
by Medi-Span in its national drug data file; and
- For services you receive outside of the United States, Puerto Rico, and the U.S. Virgin Islands
from providers that do not contract with us or with the Overseas Assistance Center (provided by
GeoBlue), we use our Overseas Fee Schedule to determine our allowance. Our fee schedule is
based on a percentage of the amounts we allow for Non-participating providers in the Washington,
D.C., area, or a customary percent of billed charge, whichever is higher.
Note: Using Non-participating or Non-member providers could result in your having to pay
significantly greater amounts for the services you receive. Non-participating and Non-member
providers are under no obligation to accept our allowance as payment in full. If you use Non-
participating and/or Non-member providers, you will be responsible for any difference between our
payment and the billed amount (except in certain circumstances involving covered Non-participating
professional care – see below). In addition, you will be responsible for any applicable deductible,
coinsurance, or copayment. You can reduce your out-of-pocket expenses by using Preferred providers
whenever possible. To locate a Preferred provider, visit www.fepblue.org/provider to use our National
Doctor & Hospital Finder, or call us at the customer service phone number on the back of your ID card.
We encourage you to always use Preferred providers for your care.
Note: For certain covered services from Non-participating professional providers, your responsibility for
the difference between the Non-participating Provider Allowance (NPA) and the billed amount may be
limited. See Section 3.
Important notice
about Non-
participating
providers!
157 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
For more information, see
Differences between our allowance and the bill
in Section 4. For more
information about how we pay providers overseas, see Section 5(i).
Any claims that are not pre-service claims. In other words, post-service claims are those claims where
treatment has been performed and the claims have been sent to us in order to apply for benefits.
Post-service claims
The requirement to contact the local Blue Cross and Blue Shield Plan serving the area where the services
will be performed before being admitted for inpatient care. Please refer to the precertification
information listed in Section 3.
Precertification
An arrangement between Local Plans and physicians, hospitals, healthcare institutions, and other covered
healthcare professionals (or for retail pharmacies, between pharmacies and CVS Caremark) to provide
services to you at a reduced cost. The PPO provides you with an opportunity to reduce your out-of-
pocket expenses for care by selecting your facilities and providers from among a specific group. PPO
providers are available in most locations; using them whenever possible helps contain healthcare costs
and reduces your out-of-pocket costs. The selection of PPO providers is solely the Local Plan’s (or for
pharmacies, CVS Caremark’s) responsibility. We cannot guarantee that any specific provider will
continue to participate in these PPO arrangements.
Preferred provider
organization (PPO)
arrangement
Those claims (1) that require precertification or prior approval, and (2) where failure to obtain
precertification or prior approval results in a reduction of benefits.
Pre-service claims
Adult preventive care includes the following services: preventive office visits and exams (including
health screening services to measure height, weight, blood pressure, heart rate, and Body Mass Index
(BMI)); general health panel; basic or comprehensive metabolic panel; fasting lipoprotein profile;
urinalysis; CBC; screening for diabetes mellitus, hepatitis B and hepatitis C, and latent tuberculosis;
screening for alcohol/substance use disorders; counseling on reducing health risks; screening for
depression; screening for chlamydia, syphilis, gonorrhea, HPV, and HIV; screening for intimate partner
violence for women of reproductive age; administration and interpretation of a Health Risk Assessment
questionnaire; cancer screenings including low-dose CT screening for lung cancer; screening for
abdominal aortic aneurysms; osteoporosis screening, as specifically stated in this brochure; and
immunizations as licensed by the U.S. Food and Drug Administration (U.S. FDA).
Note: Anesthesia services and pathology services associated with preventive colorectal surgical
screenings are also paid as preventive care.
Preventive care,
adult
Written assurance that benefits will be provided by:
1. The Local Plan where the services will be performed; or
2. The Retail Pharmacy Program, the Mail Service Prescription Drug Program, or the Specialty Drug
Pharmacy Program.
For more information, see the benefit descriptions in Section 5 and
Other services
in Section 3, under
You need prior Plan approval for certain services
.
Prior approval
A Carrier’s pursuit of a recovery if a covered individual has suffered an illness or injury and has
received, in connection with that illness or injury, a payment from any party that may be liable, any
applicable insurance policy, or a workers’ compensation program or insurance policy, and the terms of
the Carrier’s health benefits plan require the covered individual, as a result of such payment, to
reimburse the Carrier out of the payment to the extent of the benefits initially paid or provided. The right
of reimbursement is cumulative with and not exclusive of the right of subrogation.
Reimbursement
The act of returning to the country of birth, citizenship or origin. Repatriation
Services that are not related to a specific illness, injury, set of symptoms, or maternity care (other than
those routine costs associated with a clinical trial).
Routine services
An examination or test of an individual with no signs or symptoms of the specific disease for which the
examination or test is being done, to identify the potential for that disease and prevent its occurrence.
Screening service
158 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
A tooth that is whole or properly restored (restoration with amalgams or resin-based composite fillings
only); is without impairment, periodontal, or other conditions; and is not in need of the treatment
provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously
restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered a
sound natural tooth.
Sound natural tooth
Pharmaceutical products that are included on the Service Benefit Plan Specialty Drug List that are
typically high in cost and have one or more of the following characteristics:
• Injectable, infused, inhaled, or oral therapeutic agents, or products of biotechnology
• Complex drug therapy for a chronic or complex condition, and/or high potential for drug adverse
effects
• Specialized patient training on the administration of the drug (including supplies and devices needed
for administration) and coordination of care is required prior to drug therapy initiation and/or during
therapy
• Unique patient compliance and safety monitoring requirements
• Unique requirements for handling, shipping, and storage
Specialty drugs
A Carrier’s pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a
workers’ compensation program or insurance policy, as successor to the rights of a covered individual
who suffered an illness or injury and has obtained benefits from the Carrier’s health benefits plan.
Subrogation
Under the telehealth benefit, dermatologic conditions seen and treated include but are not limited to acne,
dermatitis, eczema, psoriasis, rosacea, seborrheic keratosis, fungal infections, scabies, suspicious moles,
and warts. Members capture important digital images, combine those with the comprehensive
questionnaire responses, and send those to the dermatology network without requiring a phone or video
interaction.
Telehealth
dermatology
Non-emergency services provided by phone or secure online video/messaging for minor acute
conditions, dermatology care, behavioral health and substance use disorder counseling, and nutritional
counseling. Go to www.fepblue.org/telehealth or call 855-636-1579, TTY: 711, toll free to access this
benefit. After your telehealth visit, please follow up with your primary care provider.
Telehealth services
Services provided by phone or secure online video/messaging for evaluation and management services.
This does not include the use of fax machine or email; costs associated with enabling or maintaining
providers’ telehealth (telemedicine) technologies; or fees for asynchronous services—medical
information stored and forwarded to be reviewed at a later time by a physician or healthcare practitioner
at a distant site without the patient being present. Providers must perform covered services acting within
the scope of their license or certification under applicable state law. Please note, your healthcare provider
must know when and where they can treat you. You, in turn, are responsible for accurately identifying to
your provider where you are physically located for the service you received through telehealth
(telemedicine) technologies. You and your physician must be in the same U.S. State, Territory, or foreign
country as required by applicable legislation.
Telemedicine
services
A defined number of consecutive days associated with a covered organ/tissue transplant procedure. Transplant period
A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-
urgent care claims could have one of the following impacts:
• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you
to severe pain that cannot be adequately managed without the care or treatment that is the subject of
the claim.
Urgent care claims usually involve Pre-service claims and not Post-service claims. We will judge
whether a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses
an average knowledge of health and medicine.
Urgent care claims
159 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
If you believe your claim qualifies as an urgent care claim, please contact our customer service
department using the phone number on the back of your Service Benefit Plan ID card and tell us the
claim is urgent. You may also prove that your claim is an urgent care claim by providing evidence that a
physician with knowledge of your medical condition has determined that your claim involves urgent
care.
“Us,” “we,” and “our” refer to the Blue Cross and Blue Shield Service Benefit Plan, and the local Blue
Cross and Blue Shield Plans that administer it.
Us/We/Our
“You” and “your” refer to the enrollee (the contract holder eligible for enrollment and coverage under the
Federal Employees Health Benefits Program and enrolled in the Plan) and each covered family member.
You/Your
160 2024 Blue Cross® and Blue Shield® Service Benefit Plan Section 10
Index
Do not rely only on this page; it is for your convenience and may not show all pages where the terms appear. This Index is not an
official statement of benefits.
Abortion ...............................46-48, 134-135
Accidental injury ...75-77, 87-92, 121-122,
152
Acupuncture ....................................59, 72-73
Affordable Care Act (ACA) ........8, 11, 44-46
Allergy care ................................................50
Allogeneic transplants ................................72
Alternative treatments ................................59
Ambulance ................................20, 87-88, 92
Ambulatory surgical center .......18-19, 77-81
Anesthesia .................................72-73, 75-77
Angiographies ...........................40-41, 77-81
Appeals .................................25, 27, 139-141
Applied behavior analysis (ABA) ...21-24,
51-52, 77-81
Assistant surgeon .......................................20
Autism spectrum disorder .........51-52, 77-81
Autologous transplants
Average wholesale price (AWP) ...114-119,
164
Biopsies ..........................42-44, 62-63, 77-81
Birthing centers .....................................18-19
Blood and blood plasma ............57-58, 77-81
Blood or marrow stem cell transplants
...71-72
Blue Distinction Centers ...18-19, 71-72,
81-82
for Transplants ................................21-24
Blue Distinction Specialty Care ...........18-19
Blue Health Assessment ...................125-126
Bone density tests ......................40-41, 77-81
Brand-name drugs ...............................99-102
Breast pump and supplies .....................46-48
Breast reconstruction ............................63-65
Breast prostheses and surgical bras ...55--
56
Breastfeeding support and supplies ...46-48,
57-58
Cancer tests .........................................42-44
Cardiac rehabilitation ................51-52, 77-81
Cardiovascular monitoring ........40-41, 77-81
Care Management Programs ............127-128
Case management ......82-86, 95-96, 127-128
Casts ..........................................62-63, 75-81
Catastrophic protection ..............33, 164, 166
Cervical cancer screening .....................42-46
CHAMPVA .......................................142-145
Changes for 2021 ..................................14-16
Chemotherapy ...........................51-52, 77-81
Children’s Equity Act .............................9-10
Chiropractic manipulative treatment ...51-52,
58-59
Cholesterol tests .....................42-44, 114-119
Circumcision .............................46-48, 62-63
Claims and claims filing ...12-13, 25-27, 127,
131-132, 136-141, 153, 158-160
Clinic visits ....................39-40, 77-81, 94-95
Clinical trials ...21-24, 134-135, 145,
152-154
Cognitive rehabilitation ...52-53, 77-81,
83-84
Coinsurance ................12-13, 20, 29, 33, 153
Colorectal cancer tests ..........................42-44
Colonoscopy ............42-44, 62-63, 77-81
Fecal occult blood test ....................42-44
Sigmoidoscopy ...............................42-44
Confidentiality ..............................12-13, 154
Congenital anomalies ...21-24, 62-63, 74,
153
Consultations .............................39-40, 94-95
Contact lenses ...............................53-54, 133
Contraceptive devices and drugs ...48,
114-119
Coordination of benefits ...........114-119, 142
Copayments .......12-13, 28, 33, 142, 145-147
Cosmetic surgery ..........................62-65, 153
Cost-sharing .................................28, 33, 153
Costs for covered services ....................28-34
Coverage information ..................................8
Covered facility providers ....................18-19
Covered professional providers .................17
CT scans ............................40-41, 77-81, 152
Custodial care .......................................18-19
Deductible ...........................................28, 37
Definitions ........................................152-160
Dental care ..........................66, 121-124, 164
Diabetes Management Incentive Program
....................................................164, 166
Diabetes Management Program ...............125
Diabetic education .....................59-60, 77-81
Diabetic supplies
Diabetic Meter Program ..............114-119
Insulin pumps .................................56-57
Insulin, test strips, and lancets ...114-119
Needles and disposable syringes
...114-119
Diagnostic and treatment services ...42-46,
77-81
Diagnostic tests ..............40-41, 46-49, 95-96
Dialysis ...............51-52, 56-57, 77-81, 83-84
Disease Management ........................127-128
Disputed claims process ...................139-141
Divorce ...............................................8-9, 11
DNA analysis of stool samples .............42-44
Donor expenses (transplants) .....................72
Drugs (see: Prescription drugs)
Durable medical equipment (DME) ...56-57,
153
Prosthetic devices ...55-56, 62-63, 75-81
Educational classes and programs ...59-60
EEGs ..........................................40-41, 77-81
EKGs .........................................40-41, 77-81
Emergency .................20, 26, 87-92, 121-122
Enrollment ........................................8, 10-11
Exception situations ..............................20-21
Exclusions .........................................134-135
Experimental or investigational ........153-154
Extended care benefits ..........................83-84
Eyeglasses .............................................53-54
Facility providers ................................18-19
Family planning .........................................48
Fecal occult blood test ..........................42-44
FEDVIP ............................................121, 145
fepblue mobile application .......................129
fepblue.org ...................................................4
Flexible benefits option ....................128-129
Foot care ...............................................54-55
Formulary/Preferred drug list .............98-120
Foundation for the Accreditation of Cellular
Therapy (FACT) accredited facility
Fraud ............................................................4
Freestanding ambulatory facilities ........18-19
Gender affirming care ...21-24, 55-56,
62-63
Generic drugs ......................................99-102
Generic Incentive Program ...............102-103
Genetic screening/testing ......................40-41
Health Insurance Marketplace ...............11
Health tools ..............................................125
Healthy Families ......................................125
Hearing aids and hearing services ...53,
55-56
Home health services .................................58
Home nursing care (maternity) .............46-48
Hospice care .........................................84-86
Hospital
Inpatient ..............................21, 75-77, 95
Outpatient .................................77-81, 96
Human papillomavirus (HPV) tests ......42-46
Hypertension Management Program .......126
Immunizations ..........42-46, 77-81, 114-119
Inpatient hospital benefits .........75-77, 81-82
Inpatient professional services ...21, 26,
39-40, 75-77
Insulin ...............................................114-119
Insulin pumps ........................56-57, 114-119
Laboratory and pathology services ........20
Low-dose CT screening ...........................158
Mail Service Prescription Drug Program
...99-103, 114-119, 131-132, 137-138,
164, 166
Mammograms .......................................42-44
Manipulative treatment .............58-59, 77-81
Maternity care .................................26, 46-48
Maxillofacial surgery .................................66
Medicaid ..................................................143
Medical emergency ...................20, 89, 91-92
Medical foods ................57-58, 114-119, 155
Medical supplies ............57-58, 75-81, 84-86
161 2024 Blue Cross® and Blue Shield® Service Benefit Plan Index
Medically necessary ...21, 26, 134-135, 145,
155
Medicare ..............1, 21, 83-84, 127, 142-151
Reimbursement account .....................127
Medications and supplies ..................114-119
Member facilities .......12-13, 18-19, 156-157
Mental health/substance use disorder
...46-48,
82-83, 93-97, 155
MRIs ..................................40-41, 77-81, 152
Multiple procedures ..............................62-63
MyBlue Customer eService .....................127
National Doctor & Hospital Finder ......127
Neurological testing ..................40-41, 77-81
Never Events .....................................6-7, 155
Newborn care ......................26, 39-40, 44-48
No Surprises Act (NSA) .............................32
Non-member facilities ...........12-13, 156-157
Non-participating providers ......12-13, 24, 32
Non-preferred providers .......................29-33
Nurse ............18-19, 58, 84-86, 125, 127-128
Nutritional counseling ..................42-46, 129
Observation care ....................................155
Obstetrical care .....................................46-48
Occupational therapy .................52-53, 84-86
Office visits .........37, 39-40, 94-95, 158, 164
Online Health Coach (OHC) ....................125
Oral surgery ...............................................66
Organ/tissue transplants ..................21-24, 72
Orthopedic devices ....................55-56, 77-81
Osteopathic manipulative treatment ...58-59
Osteoporosis screening ............................158
Ostomy and catheter supplies ...............57-58
Out-of-pocket expenses ........33, 37, 157-158
Outpatient facility services ...................77-81
Outpatient professional services ...........39-40
Overpayments ............................................34
Overseas Assistance Center .....................130
Overseas services, drugs, supplies and
claims ................................................130-132
Oxygen ..................................................56-58
Pap tests ...............................................42-44
Participating providers ...39-60, 62-66,
72-73, 89-92, 94-95, 124
Patient Safety and Quality Monitoring
(PSQM) Program ................................99-102
Personal Health Record ............................125
PET scans ..........................40-41, 77-81, 152
Pharmacotherapy .......................39-40, 51-52
Physical examination .............77-81, 134-135
Physical therapy .............39-40, 52-53, 84-86
Physician .......17, 21, 146, 150, 154, 163-166
Plan allowance ..................................156-157
PPO ...............................................12-13, 158
Pre-admission testing ............................75-77
Precertification ................21, 24-26, 154, 158
Preferred providers ..............12-13, 20, 29-32
Pregnancy (see: Maternity care)
Pregnancy Care Incentive Program
...126-127
Prescription drugs .............................114-119
Brand-name drugs .........99-102, 114-119
Drugs from other sources ............119-120
Generic drugs ..............................114-119
Mail Service Prescription Drug Program
......................114-119, 131-132, 137-138
Preferred retail pharmacies ...114-119,
137-138
Retail Pharmacy Program ...99-102,
114-119, 131-132, 137-138
Self-injectable drugs .......................98-99
Specialty Drug Pharmacy Program ...11-
4-119, 131-132
Specialty drugs ......99-102, 114-119, 159
Preventive care
Adult .......................................42-44, 158
Child ...............................................44-46
Primary care provider ...17, 37, 39-40, 44-46,
49-55, 59-60, 84-86
Prior approval ...21-25, 51-52, 61-66, 74,
84-86, 98-102, 114-119, 137-138,
153-154, 158
Professional providers ................................17
Prostate cancer tests ..............................42-44
Prosthetic devices ...........55-56, 62-65, 74-81
Psychotherapy .......................................94-97
Pulmonary rehabilitation ...........51-52, 77-81
Radiation therapy ....................51-52, 77-81
Reconsiderations .........................27, 139-141
Renal dialysis .................18-19, 51-52, 77-81
Replacement coverage ...............................11
Reproductive services ........................49, 152
Assisted reproductive technology (ART)
......................................................49, 152
Residential Treatment Center (RTC) ...18-19,
21, 24-25, 82-83, 95-96, 127-128, 153
Retail Pharmacy Program ...37, 98-102,
114-119, 131-132, 136-138, 158, 164,
166
Rights and responsibilities ....................12-13
Room and board ...21, 26, 39-40, 75-77,
82-84, 95-96
Screening services ..................................158
Second surgical opinion ........................39-40
Self-injectable drugs .................114-119, 159
Skilled nursing facility (SNF) care ...18-19,
153
Smoking cessation .........59-60, 114-119, 125
Social worker ....................................127-128
Specialty Drug Pharmacy Program ...98-99,
114-119, 131-132, 137-138
Specialty drugs ..........................114-119, 159
Speech therapy ...............52-53, 77-81, 84-86
Speech-Generating Devices ..................56-57
Stem Cell Transplants
Sterilization procedures ..................48, 62-63
Subrogation ...............................143-144, 159
Substance use disorder ..........93-97, 164-165
Surgery .............24, 53-54, 61-73, 81-82, 153
Assistant surgeon ......................20, 62-63
Eye: cataract, amblyopia, strabismus
.............................................53-54, 62-63
Gender affirming .................21-24, 62-63
Multiple procedures ........................62-63
Oral and maxillofacial ..........................66
Outpatient ...21-24, 51-52, 62-63, 77-81,
96, 155-156
Reconstructive ................................63-65
Sterilization, reversal of voluntary ...48,
62-63
Surgical implants .................55-56, 77-81
Surgical treatment of severe obesity ...21-
-24, 62-63
Transplants
Syringes ............................................114-119
Telehealth ................................................159
Dermatology ..............................129, 159
Mental health/substance use disorder
..............................................................38
Minor acute conditions ......129, 155, 159
Nutritional counseling ................129, 159
Temporary Continuation of Coverage (TCC)
........................................................10-11
Tobacco cessation ..........59-60, 114-119, 125
Transplants ...............18-19, 21-24, 51-52, 72
Travel benefit ................................71-72, 125
Treatment therapies ..............................51-52
TRICARE .........................................142-143
Ultrasounds ..............................40-41, 77-81
Urgent care center .................................90-92
Urgent care claims ......................25, 159-160
VA facilities .............................................150
Vision services ..............................53-54, 145
Waivers ......................................................29
Weight control ..........................125, 134-135
Wheelchairs ....................56-57, 83-84, 87-88
Wigs ......................................................55-56
X-rays ...........................................40-41, 145
162 2024 Blue Cross® and Blue Shield® Service Benefit Plan Index
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan
Standard Option – 2024
Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this
brochure. Before making a decision, please read this FEHB brochure.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your
enrollment form.
Below, an asterisk (*) means the item is subject to the $350 per person ($700 per Self Plus One or Self and Family enrollment)
calendar year deductible. If you use a Non-PPO physician or other healthcare professional, you generally pay any difference between
our allowance and the billed amount, in addition to any share of our allowance shown below.
You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.fepblue.org/
brochure.
Standard Option Benefits You pay Page
PPO: Nothing for preventive care; 15%* of our allowance; $30
per office visit for primary care providers and other healthcare
professionals
$40 per office visit for specialists
Non-PPO: 35%* of our allowance
39-45 Medical services provided by
physicians: Diagnostic and treatment services
provided in the office
PPO: Nothing for the first 2 visits per calendar year;
after the 2nd visit: $10 copayment per visit
Non-PPO: You pay all charges
39, 99 Medical services provided by
physicians: Telehealth services
PPO: $350 per admission
Non-PPO: $450 per admission, plus 35% of our allowance
75-77 Services provided by a hospital: Inpatient
PPO: 15%* of our allowance
Non-PPO: 35%* of our allowance
77-81 Services provided by a hospital: Outpatient
PPO: Nothing for outpatient hospital and physician services
within 72 hours; regular benefits thereafter
Non-PPO: Any difference between the Plan allowance and
billed amount for outpatient hospital and physician services
within 72 hours; regular benefits thereafter
Ambulance transport services: Nothing
90-91 Emergency benefits: Accidental injury
PPO urgent care: $30 copayment; PPO and Non-PPO
emergency room care: 15%* of our allowance; Regular
benefits for physician and hospital care* provided in other than
the emergency room/PPO urgent care center
Ambulance transport services: $100 per day for ground
ambulance (no deductible); $150 per day for air or sea
ambulance (no deductible)
91-92 Emergency benefits: Medical emergency
163 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard Option Summary
Standard Option Benefits You pay Page
PPO: Regular cost-sharing, such as $30 office visit copay;
$350 per inpatient admission
Non-PPO: Regular cost-sharing, such as 35%* of our
allowance for office visits; $450 per inpatient admission to
Member facilities, plus 35% of our allowance
93-97 Mental health and substance use disorder
treatment
Retail Pharmacy Program:
• PPO: $7.50 for each purchase of up to a 30-day supply
generic ($5.00 for a 30-day supply if you have Medicare
Part B primary)/30% of our allowance Preferred brand-
name/50% of our allowance non-preferred brand-name
• Non-PPO: 45% of our allowance (AWP)
Mail Service Prescription Drug Program:
• $15 generic ($10 if you have Medicare Part B primary)/$90
Preferred brand-name/$125 non-preferred brand-name per
prescription; up to a 90-day supply
Specialty Drug Pharmacy Program:
• $65 preferred specialty drug for a purchase of up to a 30-
day supply; $85 non-preferred specialty drug for a purchase
of up to a 30-day supply
103-107 Prescription drugs
Scheduled allowances for diagnostic and preventive services;
regular benefits for dental services required due to accidental
injury and covered oral and maxillofacial surgery
123 Dental care
See Section 5(h). 125-129 Wellness and other special features: Health
Tools; Blue Health Assessment; MyBlue
®
Customer eService; National Doctor and Hospital
Finder; Healthy Families; travel benefit/services
overseas; Care Management Programs; and
Flexible benefits option
• Self Only: Nothing after $6,000 (PPO) or $8,000 (PPO/
Non-PPO) per contract per year
• Self Plus One: Nothing after $12,000 (PPO) or $16,000
(PPO/Non-PPO) per contract per year
• Self and Family: Nothing after $12,000 (PPO) or $16,000
(PPO/Non-PPO) per contract per year
Note: Some costs do not count toward this protection.
Note: When one covered family member (Self Plus One and
Self and Family contracts) reaches the Self Only maximum
during the calendar year, that member’s claims will no longer
be subject to associated member cost-share amounts for the
remainder of the year. All remaining family members will be
required to meet the balance of the catastrophic protection out-
of-pocket maximum.
33-34 Protection against catastrophic costs (your
catastrophic protection out-of-pocket maximum)
164 2024 Blue Cross® and Blue Shield® Service Benefit Plan Standard Option Summary
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic
Option – 2024
Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this
brochure. Before making a decision, please read this FEHB brochure.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your
enrollment form.
Basic Option does not provide benefits when you use Non-preferred providers. For a list of the exceptions to this requirement, see
Section 3. There is no deductible for Basic Option.
You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.fepblue.org/
brochure.
Basic Option Benefits You pay Page
PPO: Nothing for preventive care; $35 per office visit for
primary care providers and other healthcare professionals; $45
per office visit for specialists
Non-PPO: You pay all charges
39-45 Medical services provided by
physicians: Diagnostic and treatment services
provided in the office
PPO: Nothing for the first 2 visits per calendar year
after the 2nd visit: $15 copayment per visit
Non-PPO: You pay all charges
39, 99 Medical services provided by
physicians: Telehealth services
PPO: $250 per day up to $1,500 per admission
Non-PPO: You pay all charges
75-77 Services provided by a hospital: Inpatient
PPO: $150 per day per facility
Non-PPO: You pay all charges
77-81 Services provided by a hospital: Outpatient
PPO: $35 copayment for urgent care; $250 copayment for
emergency room care
Non-PPO: $250 copayment for emergency room care; you pay
all charges for care in settings other than the emergency room
Ambulance transport services: $100 per day for ground
ambulance; $150 per day for air or sea ambulance
90-91 Emergency benefits: Accidental injury
Same as for accidental injury 91-92 Emergency benefits: Medical emergency
PPO: Regular cost-sharing, such as $30 office visit copayment;
$250 per day up to $1,500 per inpatient admission
Non-PPO: You pay all charges
93-97 Mental health and substance use disorder
treatment
165 2024 Blue Cross® and Blue Shield® Service Benefit Plan Basic Option Summary
Basic Option Benefits You pay Page
Retail Pharmacy Program:
• PPO: $15 generic/($10 if you have primary Medicare Part
B)/$60 Preferred brand-name per prescription ($50 if you
have primary Medicare Part B)/60% coinsurance ($90
minimum) for non-preferred brand-name drugs (50% ($60
minimum) if you have primary Medicare Part B)
• Non-PPO: You pay all charges
Specialty Drug Pharmacy Program:
• $85 preferred specialty drug for a purchase of up to a 30-
day supply; $110 non-preferred specialty drug for a
purchase of up to a 30-day supply
Mail Service Prescription Drug Program (for primary
Medicare Part B members only):
• $20 generic/$100 Preferred brand-name/$125 non-preferred
brand-name per prescription; up to a 90-day supply
103-107 Prescription drugs
PPO: $35 copayment per evaluation (exam, cleaning, and
X-rays); most services limited to 2 per year; sealants for
children up to age 16; $35 copayment for associated oral
evaluations required due to accidental injury; regular benefits
for covered oral and maxillofacial surgery
Non-PPO: You pay all charges
124 Dental care
See Section 5(h). 125-129 Wellness and other special features: Health
Tools; Blue Health Assessment; MyBlue
®
Customer eService; National Doctor and Hospital
Finder; Healthy Families; travel benefit/services
overseas; Care Management Programs; and
Flexible benefits option
• Self Only: Nothing after $6,500 (PPO) per contract per year
• Self Plus One: Nothing after $13,000 (PPO) per contract
per year
• Self and Family: Nothing after $13,000 (PPO) per contract
per year; nothing after $6,500 (PPO) per individual per year
Note: Some costs do not count toward this protection.
Note: When one covered family member (Self Plus One and
Self and Family contracts) reaches the Self Only maximum
during the calendar year, that member’s claims will no longer
be subject to associated member cost-share amounts for the
remainder of the year. All remaining family members will be
required to meet the balance of the catastrophic protection out-
of-pocket maximum.
33-34 Protection against catastrophic costs (your
catastrophic protection out-of-pocket maximum)
166 2024 Blue Cross® and Blue Shield® Service Benefit Plan Basic Option Summary
Notes
167 2024 Blue Cross® and Blue Shield® Service Benefit Plan Notes
Notes
168 2024 Blue Cross® and Blue Shield® Service Benefit Plan Notes
Notes
169 2024 Blue Cross® and Blue Shield® Service Benefit Plan Notes
2024 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan
To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.
To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums
or www.opm.gov/Tribalpremium.
Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution
is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your
Tribal Benefits Officer for exact rates.
Type of Enrollment Enrollment
Code
Premium Rate
Biweekly Monthly
Gov't
Share
Your
Share
Gov't
Share
Your
Share
Nationwide
Standard Option
Self Only
104 $271.43 $150.79 $588.10 $326.71
Standard Option
Self Plus One
106 $586.50 $336.84 $1,270.75 $729.82
Standard Option
Self and Family
105 $646.18 $370.68 $1,400.06 $803.14
Nationwide
Basic Option Self
Only
111 $271.43 $95.74 $588.10 $207.44
Basic Option Self
Plus One
113 $586.50 $238.63 $1,270.75 $517.03
Basic Option Self
and Family
112 $646.18 $262.60 $1,400.06 $568.96
170 2024 Blue Cross® and Blue Shield® Service Benefit Plan Rates
