Blue Cross and Blue Shield Service Benefit Plan Brochure - 2027

PSHB FEP Blue Standard and FEP Blue Basic Options

 

Document list

Document Name Document Number
Cover page SBP.27.00.1.01
Inside cover SBP.27.00.1.02
Table of Contents SBP.27.00.1.03
Introduction SBP.27.00.2.01
Plain Language SBP.27.00.2.02
Stop Healthcare Fraud! SBP.27.00.2.03
Discrimination is Against the Law SBP.27.00.2.04
Preventing Medical Mistakes SBP.27.00.2.05
No pre-existing condition limitation SBP.27.00.3.1.01
Minimum essential coverage (MEC) SBP.27.00.3.1.02
Minimum value standard SBP.27.00.3.1.03
Where you can get information about enrolling in the PSHB Program SBP.27.00.3.1.05
Enrollment types available for you and your family SBP.27.00.3.1.06
Family member coverage SBP.27.00.3.1.07
Children's Equity Act SBP.27.00.3.1.08
Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) SBP.27.00.3.1.09
When benefits and premiums start SBP.27.00.3.1.10
When you retire SBP.27.00.3.1.11
When PSHB coverage ends SBP.27.00.3.2.02
Upon divorce SBP.27.00.3.2.03
Medicare PDP EGWP SBP.27.00.3.2.05
Temporary Continuation of Coverage (TCC) SBP.27.00.3.2.06
Finding replacement coverage SBP.27.00.3.2.07
Health Insurance Marketplace SBP.27.00.3.2.08
Section 1. How This Plan Works SBP.27.01.00
General features of our Standard and Basic Options//We have a Preferred Provider Organization (PPO) SBP.27.01.01
How we pay professional and facility providers SBP.27.01.03
Your rights and responsibilities SBP.27.01.04
Your medical and claims records are confidential SBP.27.01.05
Section 2. Changes for 2027 SBP.27.02.00
Identification cards SBP.27.03.01
Where you get covered care SBP.27.03.02
Balance Billing Protection SBP.27.03.03
Covered professional providers SBP.27.03.04
Covered facility providers SBP.27.03.05
What you must do to get covered care SBP.27.03.06
Transitional care SBP.27.03.07
If you are hospitalized when your enrollment begins SBP.27.03.08
You need prior Plan Approval for certain services SBP.27.03.4.00
Inpatient hospital, residential treatment center, or skilled nursing facility admission SBP.27.03.4.01
Other services SBP.27.03.4.03
Surgery by Non-participating providers under Standard Option SBP.27.03.4.04
Special prior authorization situations related to coordination of benefits (COB) SBP.27.03.4.05
How to request precertification for an admission or get approval for Other services SBP.27.03.4.07
Non-urgent care claims SBP.27.03.4.08
Urgent care claims SBP.27.03.4.09
Concurrent care claims SBP.27.03.4.10
Emergency inpatient admission SBP.27.03.4.11
Maternity care SBP.27.03.4.12
If your facility stay needs to be extended SBP.27.03.4.13
If your treatment needs to be extended SBP.27.03.4.14
If you disagree with our pre-service claim decision SBP.27.03.5.00
To reconsider a non-urgent care claim SBP.27.03.5.01
To reconsider an urgent care claim SBP.27.03.5.02
To file an appeal with OPM SBP.27.03.5.03
Cost-share/Cost-sharing SBP.27.04.01
Copayment SBP.27.04.02
Deductible SBP.27.04.03
Coinsurance SBP.27.04.04
If your provider routinely waives your cost SBP.27.04.05
Waivers SBP.27.04.06
Differences between our allowance and the bill SBP.27.04.07
Important Notice About Surprise Billing – Know Your Rights SBP.27.04.08
Your costs for other care SBP.27.04.09
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments SBP.27.04.10
Carryover SBP.27.04.11
If we overpay you SBP.27.04.12
When Government facilities bill us SBP.27.04.13
Section 5. Benefits [Table of Contents] SBP.27.05.01
Section 5. Standard and Basic Option Overview SBP.27.05.02
Section 5(a). Overview SBP.27.05a.00
Diagnostic and Treatment Services SBP.27.05a.01
Lab, X-ray and Other Diagnostic Tests SBP.27.05a.02
Preventive Care, Adult SBP.27.05a.03
Preventive Care, Child SBP.27.05a.04
Maternity Care SBP.27.05a.05
Family Planning SBP.27.05a.06
Reproductive Services SBP.27.05a.07
Allergy Care SBP.27.05a.08
Treatment Therapies SBP.27.05a.09
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy SBP.27.05a.10
Hearing Services (Testing, Treatment, and Supplies) SBP.27.05a.11
Vision Services (Testing, Treatment, and Supplies) SBP.27.05a.12
Foot Care SBP.27.05a.13
Orthopedic and Prosthetic Devices SBP.27.05a.14
Durable Medical Equipment (DME) SBP.27.05a.15
Medical Supplies SBP.27.05a.16
Home Health Services SBP.27.05a.17
Manipulative Treatment SBP.27.05a.18
Alternative Treatments SBP.27.05a.19
Educational Classes and Programs SBP.27.05a.21
Section 5(b). Overview SBP.27.05b.00
Surgical Procedures SBP.27.05b.01
Reconstructive Surgery SBP.27.05b.02
Oral and Maxillofacial Surgery SBP.27.05b.03
Organ/Tissue Transplants SBP.27.05b.04
Anesthesia SBP.27.05b.05
Section 5(c). Overview SBP.27.05c.00
Inpatient Hospital SBP.27.05c.01
Outpatient Hospital or Ambulatory Surgical Center SBP.27.05c.03
Blue Distinction Specialty Care SBP.27.05c.03.01
Residential Treatment Center - 5(c) SBP.27.05c.04
Extended Care Benefits/Skilled Nursing Care Facility Benefits SBP.27.05c.05
Hospice Care SBP.27.05c.06
Ambulance SBP.27.05c.07
Section 5(d). Overview SBP.27.05d.00
Accidental Injury SBP.27.05d.01
Medical Emergency SBP.27.05d.02
Ambulance SBP.27.05d.03
Section 5(e). Overview SBP.27.05e.00
Professional Services SBP.27.05e.01
Inpatient Hospital or Other Covered Facility SBP.27.05e.02
Residential Treatment Center - 5(e) SBP.27.05e.03
Outpatient Hospital or Other Covered Facility SBP.27.05e.04
Not Covered (Inpatient or Outpatient) SBP.27.05e.05
Section 5(f). Overview SBP.27.05f.00
There are important features you should be aware of SBP.27.05f.01
Who can write your prescriptions SBP.27.05f.02
Where you can obtain them SBP.27.05f.03
What is covered SBP.27.05f.04
Generic equivalents SBP.27.05f.05
Disclosure of information SBP.27.05f.06
These are the dispensing limitations SBP.27.05f.07
Patient Safety and Quality Monitoring (PSQM) SBP.27.05f.08
Prior Approval SBP.27.05f.09
Standard Option Generic Incentive Program SBP.27.05f.10
Medical Foods SBP.27.05f.11
Here is how to obtain your prescription drugs and supplies SBP.27.05f.12
Preferred Retail Pharmacies SBP.27.05f.13
Non-preferred Retail Pharmacies SBP.27.05f.14
Mail Service Prescription Drug Program SBP.27.05f.15
Specialty Drug Pharmacy Program SBP.27.05f.16
Asthma Medications SBP.27.05f.17
Other Preferred Diabetic Medications, Test Strips, and Supplies SBP.27.05f.18
Diabetic Meter Program SBP.27.05f.19
Anti-hypertensive Medications SBP.27.05f.19.01.01
Over-the-counter (OTC) contraceptive drugs and devices SBP.27.05f.19.02
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network SBP.27.05f.19.03
Metformin and metformin extended release (excluding osmotic and modified release generic drugs) SBP.27.05f.19.04
Medications to promote better health as recommended under the ACA SBP.27.05f.19.05
Generic medications to reduce breast cancer risk for women SBP.27.05f.19.06
Bowel preparation medications and antiretroviral therapy medications for HIV SBP.27.05f.19.07
Opioid Rescue Agents SBP.27.05f.19.08
Smoking and Tobacco Cessation Medications SBP.27.05f.19.08.01
Not Covered SBP.27.05f.19.09
Drugs From Other Sources SBP.27.05f.19.10
Section 5(f). MPDP Overview and 5(f)(a). Overview SBP.27.05f.20
MPDP There are important features you should be aware of SBP.27.05f.21
MPDP Who can write your prescriptions SBP.27.05f.22
MPDP Where you can obtain prescription drugs SBP.27.05f.23
MPDP Generic equivalents SBP.27.05f.25
MPDP Disclosure of information SBP.27.05f.26
MPDP We have a managed formulary SBP.27.05f.27
MPDP These are the dispensing limitations SBP.27.05f.28
MPDP Important Contact Information SBP.27.05f.29
MPDP Prior Approval SBP.27.05f.30
MPDP Medical Foods SBP.27.05f.31
MPDP How to obtain your prescription drugs and supplies SBP.27.05f.32
MPDP When you do have to file a claim SBP.27.05f.33
MPDP Catastrophic Maximums SBP.27.05f.34
MPDP Retail Pharmacies SBP.27.05f.35
MPDP Mail Service Prescription Drug Program SBP.27.05f.36
MPDP Asthma Medications SBP.27.05f.37
MPDP Other Preferred Diabetic Medications, Test Strips, and Supplies SBP.27.05f.38
Smoking and Tobacco Cessation Medications SBP.27.05f.39
Anti-hypertensive Medications SBP.27.05f.41
Over-the-counter (OTC) contraceptive drugs and devices SBP.27.05f.42
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network SBP.27.05f.43
Metformin and metformin extended release (excluding osmotic and modified release generic drugs) SBP.27.05f.44
Medications to promote better health as recommended under the ACA SBP.27.05f.45
Generic medications to reduce breast cancer risk for women SBP.27.05f.46
Bowel preparation medications and antiretroviral therapy medications for HIV SBP.27.05f.47
Opioid Rescue Agents SBP.27.05f.48
Not Covered SBP.27.05f.50
Drugs From Other Sources SBP.27.05f.51
Section 5(g). Overview SBP.27.05g.00
Accidental Injury Benefit SBP.27.05g.01
Dental Benefits SBP.27.05g.02
Health Tools SBP.27.05h.02
Paperless EOBs Incentive SBP.27.05h.02.01
Services for the Deaf and Hearing Impaired SBP.27.05h.03
Web Accessibility for the Visually Impaired SBP.27.05h.04
Travel Benefit/Services Overseas SBP.27.05h.05
Healthy Families SBP.27.05h.06
Diabetes Management Program SBP.27.05h.07
Blue Health Assessment SBP.27.05h.08
Hypertension Management Program SBP.27.05h.09
Pregnancy Care Incentive Program SBP.27.05h.10
Annual Incentive Limitation SBP.27.05h.11
Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B SBP.27.05h.12
MyBlue Customer eService SBP.27.05h.13
National Doctor & Hospital Finder SBP.27.05h.14
Care Management Programs SBP.27.05h.15
Flexible Benefits Option SBP.27.05h.16
Telehealth Services SBP.27.05h.17
The fepblue Mobile Application SBP.27.05h.19
Weight Loss Management Program SBP.27.05h.20
Section 5(i). Services, Drugs, and Supplies Provided Overseas SBP.27.05i.00
Non-PSHB Benefits Available to Plan Members SBP.27.05N.01
Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover SBP.27.06.00
Section 7. Filing a Claim for Covered Services SBP.27.07.00
Section 8. The Disputed Claims Process SBP.27.08.00
Section 8(a). Medicare PDP EGWP Disputed Claims Process SBP.27.09.01.00
When you have other health coverage SBP.27.09.01.01
TRICARE and CHAMPVA SBP.27.09.01.02
Workers' Compensation SBP.27.09.01.03
Medicaid SBP.27.09.02
When other Government agencies are responsible for your care SBP.27.09.03
When others are responsible for injuries SBP.27.09.04
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) SBP.27.09.05
Clinical trials SBP.27.09.06.01
When you have Medicare SBP.27.09.06.02
The Original Medicare Plan (Part A or Part B) SBP.27.09.06.03
Tell us about your Medicare coverage SBP.27.09.06.04
Private contract with your physician SBP.27.09.06.05
Medicare Advantage (Part C) SBP.27.09.06.06
Medicare prescription drug coverage (Part D) SBP.27.09.06.07
Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) SBP.27.09.06.08
Medicare prescription drug coverage (Part B) SBP.27.09.06.09
Primary payor chart SBP.27.09.07
When you are age 65 or over and do not have Medicare SBP.27.09.08
Physicians Who Opt-Out of Medicare SBP.27.09.09
When you have the Original Medicare Plan (Part A, Part B, or both) SBP.27.09.10
Cost-share when Medicare is your primary payor SBP.27.09.11
Section 10. Definitions of Terms We Use in This Brochure SBP.27.10.00
Index SBP.27.11.00
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2027 SBP.27.12.01
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2027 SBP.27.12.02
2027 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan SBP.27.13.00
Quick Links SBP.27.QL
Terms and Conditions and Privacy Notice SBP.27.TC