Coverage information - 9
• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the PSHB Program - 9
• Enrollment types available for you and your family - 9
• Family Member Coverage - 10
• Children’s Equity Act - 11
• Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) - 11
• When benefits and premiums start - 11
• When you retire - 12
When you lose benefits - 12
• When PSHB coverage ends - 12
• Upon divorce - 12
• Medicare PDP EGWP - 12
• Temporary Continuation of Coverage (TCC) - 13
• Finding replacement coverage - 13
• Health Insurance Marketplace - 13

Section 1. How This Plan Works - 14

General features of our Standard and Basic Options - 14
We have a Preferred Provider Organization (PPO) - 14
How we pay professional and facility providers - 14
Your rights and responsibilities - 15
Your medical and claims records are confidential - 15

Section 2. Changes for 2027 - 16
Section 3. How You Get Care - 20

Identification cards - 20
Where you get covered care - 20
Balance Billing Protection - 20
• Covered professional providers - 20
• Covered facility providers - 20
What you must do to get covered care - 22
• Transitional care - 23
• If you are hospitalized when your enrollment begins - 23
You need prior Plan approval for certain services - 24
• Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility admission - 24
• Other services - 24
• Surgery by Non-participating providers under Standard Option - 27
How to request precertification for an admission or get prior authorization for Other services - 27
• Non-urgent care claims - 28
• Urgent care claims - 28
• Concurrent care claims - 28
• Emergency inpatient admission - 29
• Maternity care - 29
• If your facility stay needs to be extended - 29
• If your treatment needs to be extended - 29
If you disagree with our pre-service claim decision - 29
• To reconsider a non-urgent care claim - 29
• To reconsider an urgent care claim - 30
• To file an appeal with OPM - 30

Section 4. Your Costs for Covered Services - 31

Cost-share/Cost-sharing - 31
Copayment - 31
Deductible - 31
Coinsurance - 32
If your provider routinely waives your cost - 32
Waivers - 32
Differences between our allowance and the bill - 32
Important Notice About Surprise Billing — Know Your Rights - 35
Your costs for other care - 35
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 36
Carryover - 37
If we overpay you - 37
When Government facilities bill us - 37

Section 5. Benefits - 38
Non-PSHB Benefits Available to Plan Members - 146
Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover - 147
Section 7. Filing a Claim for Covered Services - 149
Section 8. The Disputed Claims Process - 153
Section 8(a). Medicare PDP EGWP Disputed Claims Process - 156
Section 9. Coordinating Benefits With Medicare and Other Coverage - 157

When you have other health coverage - 157
• TRICARE and CHAMPVA - 157
• Workers’ Compensation - 158
• Medicaid - 158
When other Government agencies are responsible for your care - 158
When others are responsible for injuries - 158
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 159
Clinical trials - 159
When you have Medicare - 160
• The Original Medicare Plan (Part A or Part B) - 160
• Tell us about your Medicare coverage - 161
• Private contract with your physician - 161
• Medicare Advantage (Part C) - 161
• Medicare prescription drug coverage (Part D) - 162
• Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) - 162
• Medicare prescription drug coverage (Part B) - 163
When you are age 65 or over and do not have Medicare - 165
Physicians Who Opt-Out of Medicare - 166
When you have the Original Medicare Plan (Part A, Part B, or both) - 166

Section 10. Definitions of Terms We Use in This Brochure - 168
Index - 178
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2027 - 180
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2027 - 182
2027 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan - 184