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Cover page
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SB24.00.1.1
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Inside cover
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SB24.00.1.2
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Table of Contents
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SB24.00.1.3
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Introduction
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SB24.00.2.1
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Plain Language
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SB24.00.2.2
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Stop Healthcare Fraud!
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SB24.00.2.3
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Discrimination is Against the Law
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SB24.00.2.4
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Preventing Medical Mistakes
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SB24.00.2.5
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No pre-existing condition limitation
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SB24.00.3.1.1
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Minimum essential coverage (MEC)
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SB24.00.3.1.2
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Minimum value standard
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SB24.00.3.1.3
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Where you can get information about enrolling in the FEHB Program
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SB24.00.3.1.4
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Enrollment types available for you and your family
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SB24.00.3.1.5
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Family member coverage
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SB24.00.3.1.6
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Children's Equity Act
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SB24.00.3.1.7
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When benefits and premiums start
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SB24.00.3.1.8
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When you retire
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SB24.00.3.1.9
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When FEHB coverage ends
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SB24.00.3.2.1
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Upon divorce
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SB24.00.3.2.2
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Temporary Continuation of Coverage (TCC)
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SB24.00.3.2.3
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Finding replacement coverage
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SB24.00.3.2.4
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Health Insurance Marketplace
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SB24.00.3.2.5
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Section 1. How This Plan Works
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SB24.01.0
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General features of our Standard and Basic Options//We have a Preferred Provider Organization (PPO)
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SB24.01.1
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How we pay professional and facility providers
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SB24.01.2
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Your rights and responsibilities
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SB24.01.3
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Your medical and claims records are confidential
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SB24.01.4
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Section 2. Changes for 2024
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SB24.02.0
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Changes to our Standard Option only
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SB24.02.1
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Changes to our Basic Option only
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SB24.02.2
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Changes to both our Standard and Basic Options
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SB24.02.3
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Identification cards
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SB24.03.1
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Where you get covered care
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SB24.03.2.0
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Balance Billing Protection
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SB24.03.2.05
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Covered professional providers
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SB24.03.2.1
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Covered facility providers
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SB24.03.2.2
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What you must do to get covered care
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SB24.03.3.0
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Transitional care
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SB24.03.3.1
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If you are hospitalized when your enrollment begins
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SB24.03.3.2
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You need prior Plan Approval for certain services
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SB24.03.4.00
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Inpatient hospital/residential treatment center/skilled nursing facility admission
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SB24.03.4.01
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Other services
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SB24.03.4.02
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Surgery by Non-participating providers under Standard Option
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SB24.03.4.03
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How to request precertification for an admission or get approval for Other services
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SB24.03.4.04
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Non-urgent care claims
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SB24.03.4.05
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Urgent care claims
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SB24.03.4.06
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Concurrent care claims
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SB24.03.4.07
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Emergency inpatient admission
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SB24.03.4.08
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Maternity care
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SB24.03.4.09
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If your facility stay needs to be extended
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SB24.03.4.10
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If your treatment needs to be extended
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SB24.03.4.11
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If you disagree with our pre-service claim decision
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SB24.03.5.0
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To reconsider a non-urgent care claim
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SB24.03.5.1
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To reconsider an urgent care claim
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SB24.03.5.2
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To file an appeal with OPM
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SB24.03.5.3
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Cost share/Cost-sharing
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SB24.04.01
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Copayment
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SB24.04.02
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Deductible
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SB24.04.03
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Coinsurance
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SB24.04.04
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If your provider routinely waives your cost
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SB24.04.05
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Waivers
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SB24.04.06
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Differences between our allowance and the bill
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SB24.04.07
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Important Notice About Surprise Billing — Know Your Rights
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SB24.04.08
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Your costs for other care
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SB24.04.09
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Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments
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SB24.04.10
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Carryover
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SB24.04.11
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If we overpay you
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SB24.04.12
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When Government facilities bill us
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SB24.04.13
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The Federal Flexible Spending Account Program – FSAFEDS
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SB24.04.14
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Section 5. Benefits
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SB24.05.01
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Section 5. Standard and Basic Option Overview
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SB24.05.02
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Section 5(a). Overview
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SB24.05a.0
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Diagnostic and Treatment Services
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SB24.05a.01
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Lab, X-ray and Other Diagnostic Tests
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SB24.05a.02
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Preventive Care, Adult
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SB24.05a.03
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Preventive Care, Child
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SB24.05a.04
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Maternity Care
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SB24.05a.05
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Family Planning
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SB24.05a.06
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Reproductive Services
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SB24.05a.07
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Allergy Care
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SB24.05a.08
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Treatment Therapies
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SB24.05a.09
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Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy
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SB24.05a.10
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Hearing Services (Testing, Treatment, and Supplies)
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SB24.05a.11
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Vision Services (Testing, Treatment, and Supplies)
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SB24.05a.12
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Foot Care
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SB24.05a.13
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Orthopedic and Prosthetic Devices
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SB24.05a.14
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Durable Medical Equipment (DME)
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SB24.05a.15
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Medical Supplies
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SB24.05a.16
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Home Health Services
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SB24.05a.17
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Manipulative Treatment
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SB24.05a.18
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Alternative Treatments
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SB24.05a.19
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Educational Classes and Programs
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SB24.05a.20
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Section 5(b). Overview
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SB24.05b.0
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Surgical Procedures
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SB24.05b.1
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Reconstructive Surgery
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SB24.05b.2
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Oral and Maxillofacial Surgery
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SB24.05b.3
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Organ/Tissue Transplants
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SB24.05b.4
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Anesthesia
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SB24.05b.5
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Section 5(c). Overview
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SB24.05c.0
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Inpatient Hospital
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SB24.05c.1
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Outpatient Hospital or Ambulatory Surgical Center
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SB24.05c.2
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Blue Distinction Specialty Care
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SB24.05c.3
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Residential Treatment Center
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SB24.05c.4
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Extended Care Benefits/Skilled Nursing Care Facility Benefits
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SB24.05c.5
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Hospice Care
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SB24.05c.6
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Ambulance
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SB24.05c.7
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Section 5(d). Overview
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SB24.05d.0
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Accidental Injury
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SB24.05d.1
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Medical Emergency
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SB24.05d.2
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Ambulance
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SB24.05d.3
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Section 5(e). Overview
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SB24.05e.0
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Professional Services
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SB24.05e.1
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Inpatient Hospital or Other Covered Facility
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SB24.05e.2
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Residential Treatment Center
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SB24.05e.3
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Outpatient Hospital or Other Covered Facility
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SB24.05e.4
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Not Covered (Inpatient or Outpatient)
|
SB24.05e.5
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Section 5(f). Overview
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SB24.05f.0
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There are important features you should be aware of
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SB24.05f.01
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Who can write your prescriptions
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SB24.05f.02
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Where you can obtain them
|
SB24.05f.03
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What is covered
|
SB24.05f.04
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Generic equivalents
|
SB24.05f.05
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Disclosure of information
|
SB24.05f.06
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These are the dispensing limitations
|
SB24.05f.07
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Patient Safety and Quality Monitoring (PSQM)
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SB24.05f.08
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Prior Approval
|
SB24.05f.09
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Standard Option Generic Incentive Program
|
SB24.05f.10
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Medical Foods
|
SB24.05f.11
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Here is how to obtain your prescription drugs and supplies
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SB24.05f.12
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Preferred Retail Pharmacies
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SB24.05f.13
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Non-preferred Retail Pharmacies
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SB24.05f.14
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Mail Service Prescription Drug Program
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SB24.05f.15
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Specialty Drug Pharmacy Program
|
SB24.05f.16
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Asthma Medications
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SB24.05f.17
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Other Preferred Diabetic Medications, Test Strips, and Supplies
|
SB24.05f.18
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Diabetic Meter Program
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SB24.05f.19
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Section 5(f). MPDP Overview
|
SB24.05f.20
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MPDP There are important features you should be aware of
|
SB24.05f.21
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MPDP Who can write your prescriptions
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SB24.05f.22
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MPDP Where you can obtain them
|
SB24.05f.23
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MPDP What is covered
|
SB24.05f.24
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MPDP Generic equivalents
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SB24.05f.25
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MPDP Disclosure of information
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SB24.05f.26
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MPDP These are the dispensing limitations
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SB24.05f.27
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MPDP Important Contact Information
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SB24.05f.28
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MPDP Prior Approval
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SB24.05f.29
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MPDP Medical Foods
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SB24.05f.30
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MPDP Here is how to obtain your prescription drugs and supplies
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SB24.05f.31
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MPDP Catastrophic Maximums
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SB24.05f.32
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MPDP Retail Pharmacies
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SB24.05f.33
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MPDP Mail Service Prescription Drug Program
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SB24.05f.34
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MPDP Asthma Medications
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SB24.05f.35
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MPDP Other Preferred Diabetic Medications, Test Strips, and Supplies
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SB24.05f.36
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Smoking and Tobacco Cessation Medications
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SB24.05f.37
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Anti-hypertensive Medications
|
SB24.05f.38
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Over-the-counter (OTC) contraceptive drugs and devices
|
SB24.05f.39
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Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network
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SB24.05f.40
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Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
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SB24.05f.41
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Medications to promote better health as recommended under the ACA
|
SB24.05f.42
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Generic medications to reduce breast cancer risk for women
|
SB24.05f.43
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Bowel preparation medications and antiretroviral therapy medications for HIV
|
SB24.05f.44
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Opioid Reversal Agents: Tier 1 medications limited to generic naloxone spray and injectable
|
SB24.05f.45
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Not Covered
|
SB24.05f.46
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Drugs From Other Sources
|
SB24.05f.47
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Section 5(g). Overview
|
SB24.05g.0
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Accidental Injury Benefit
|
SB24.05g.1
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Dental Benefits
|
SB24.05g.2
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Health Tools
|
SB24.05h.01
|
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Services for the Deaf and Hearing Impaired
|
SB24.05h.02
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Web Accessibility for the Visually Impaired
|
SB24.05h.03
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Travel Benefit/Services Overseas
|
SB24.05h.04
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Healthy Families
|
SB24.05h.05
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Diabetes Management Program
|
SB24.05h.06
|
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Blue Health Assessment
|
SB24.05h.07
|
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Hypertension Management Program
|
SB24.05h.08
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Pregnancy Care Incentive Program
|
SB24.05h.09
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Annual Incentive Limitation
|
SB24.05h.10
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Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B
|
SB24.05h.11
|
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MyBlue Customer eService
|
SB24.05h.12
|
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National Doctor & Hospital Finder
|
SB24.05h.13
|
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Care Management Programs
|
SB24.05h.14
|
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Flexible Benefits Option
|
SB24.05h.15
|
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Telehealth Services
|
SB24.05h.16
|
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The fepblue Mobile Application
|
SB24.05h.17
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Section 5(i). Services, Drugs, and Supplies Provided Overseas
|
SB24.05i.0
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Non-FEHB Benefits Available to Plan Members
|
SB24.05N.0
|
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Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover
|
SB24.06
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Section 7. Filing a Claim for Covered Services
|
SB24.07
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Section 8. The Disputed Claims Process
|
SB24.08
|
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When you have other health coverage
|
SB24.09.1.0
|
|
TRICARE and CHAMPVA
|
SB24.09.1.1
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Workers' Compensation
|
SB24.09.1.2
|
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Medicaid
|
SB24.09.1.3
|
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When other Government agencies are responsible for your care
|
SB24.09.2
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When others are responsible for injuries
|
SB24.09.3
|
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When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP)
|
SB24.09.4
|
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Clinical trials
|
SB24.09.5
|
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When you have Medicare
|
SB24.09.6.1
|
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The Original Medicare Plan (Part A or Part B)
|
SB24.09.6.2
|
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Tell us about your Medicare coverage
|
SB24.09.6.3
|
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Private contract with your physician
|
SB24.09.6.4
|
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Medicare Advantage (Part C)
|
SB24.09.6.5
|
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Medicare prescription drug coverage (Part D)
|
SB24.09.6.6
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Medicare prescription drug coverage (Part B)
|
SB24.09.6.7
|
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Primary payor chart
|
SB24.09.6.8
|
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When you are age 65 or over and do not have Medicare
|
SB24.09.7
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Physicians Who Opt-Out of Medicare
|
SB24.09.8
|
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When you have the Original Medicare Plan (Part A, Part B, or both)
|
SB24.09.9
|
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Cost-share when Medicare is your primary payor
|
SB24.09.95
|
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Section 10. Definitions of Terms We Use in This Brochure
|
SB24.10
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Index
|
SB24.11
|
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Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2024
|
SB24.12.1
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Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2024
|
SB24.12.2
|
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2024 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan
|
SB24.13
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Cover page
|
SB24-000-1
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Inside cover
|
SB24-000-2
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1
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SB24-001
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2
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SB24-002
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3
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SB24-003
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4
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SB24-004
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5
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SB24-005
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6
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SB24-006
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7
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SB24-007
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8
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SB24-008
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9
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SB24-009
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10
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SB24-010
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11
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SB24-011
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12
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SB24-012
|
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13
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SB24-013
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14
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SB24-014
|
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15
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SB24-015
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16
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SB24-016
|
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17
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SB24-017
|
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18
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SB24-018
|
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19
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SB24-019
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20
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SB24-020
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21
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SB24-021
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22
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SB24-022
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23
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SB24-023
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24
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SB24-024
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25
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SB24-025
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26
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SB24-026
|
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27
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SB24-027
|
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28
|
SB24-028
|
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29
|
SB24-029
|
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30
|
SB24-030
|
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31
|
SB24-031
|
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32
|
SB24-032
|
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33
|
SB24-033
|
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34
|
SB24-034
|
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35
|
SB24-035
|
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36
|
SB24-036
|
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37
|
SB24-037
|
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38
|
SB24-038
|
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39
|
SB24-039
|
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40
|
SB24-040
|
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41
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SB24-041
|
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42
|
SB24-042
|
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43
|
SB24-043
|
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44
|
SB24-044
|
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45
|
SB24-045
|
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46
|
SB24-046
|
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47
|
SB24-047
|
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48
|
SB24-048
|
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49
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SB24-049
|
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50
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SB24-050
|
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51
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SB24-051
|
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52
|
SB24-052
|
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53
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SB24-053
|
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54
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SB24-054
|
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55
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SB24-055
|
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56
|
SB24-056
|
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57
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SB24-057
|
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58
|
SB24-058
|
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59
|
SB24-059
|
|
60
|
SB24-060
|
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61
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SB24-061
|
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62
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SB24-062
|
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63
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SB24-063
|
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64
|
SB24-064
|
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65
|
SB24-065
|
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66
|
SB24-066
|
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67
|
SB24-067
|
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68
|
SB24-068
|
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69
|
SB24-069
|
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70
|
SB24-070
|
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71
|
SB24-071
|
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72
|
SB24-072
|
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73
|
SB24-073
|
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74
|
SB24-074
|
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75
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SB24-075
|
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76
|
SB24-076
|
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77
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SB24-077
|
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78
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SB24-078
|
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79
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SB24-079
|
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80
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SB24-080
|
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81
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SB24-081
|
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82
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SB24-082
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83
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SB24-083
|
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84
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SB24-084
|
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85
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SB24-085
|
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86
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SB24-086
|
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87
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SB24-087
|
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88
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SB24-088
|
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89
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SB24-089
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90
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SB24-090
|
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91
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SB24-091
|
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92
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SB24-092
|
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93
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SB24-093
|
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94
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SB24-094
|
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95
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SB24-095
|
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96
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SB24-096
|
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97
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SB24-097
|
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98
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SB24-098
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99
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SB24-099
|
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100
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SB24-100
|
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101
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SB24-101
|
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102
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SB24-102
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103
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SB24-103
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104
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SB24-104
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105
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SB24-105
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106
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SB24-106
|
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107
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SB24-107
|
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108
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SB24-108
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109
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SB24-109
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110
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SB24-110
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111
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SB24-111
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112
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SB24-112
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113
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SB24-113
|
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114
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SB24-114
|
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115
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SB24-115
|
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116
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SB24-116
|
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117
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SB24-117
|
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118
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SB24-118
|
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119
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SB24-119
|
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120
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SB24-120
|
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121
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SB24-121
|
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122
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SB24-122
|
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123
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SB24-123
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124
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SB24-124
|
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125
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SB24-125
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126
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SB24-126
|
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127
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SB24-127
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128
|
SB24-128
|
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129
|
SB24-129
|
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130
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SB24-130
|
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131
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SB24-131
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132
|
SB24-132
|
|
133
|
SB24-133
|
|
134
|
SB24-134
|
|
135
|
SB24-135
|
|
136
|
SB24-136
|
|
137
|
SB24-137
|
|
138
|
SB24-138
|
|
139
|
SB24-139
|
|
140
|
SB24-140
|
|
141
|
SB24-141
|
|
142
|
SB24-142
|
|
143
|
SB24-143
|
|
144
|
SB24-144
|
|
145
|
SB24-145
|
|
146
|
SB24-146
|
|
147
|
SB24-147
|
|
148
|
SB24-148
|
|
149
|
SB24-149
|
|
150
|
SB24-150
|
|
151
|
SB24-151
|
|
152
|
SB24-152
|
|
153
|
SB24-153
|
|
154
|
SB24-154
|
|
155
|
SB24-155
|
|
156
|
SB24-156
|
|
157
|
SB24-157
|
|
158
|
SB24-158
|
|
159
|
SB24-159
|
|
160
|
SB24-160
|
|
161
|
SB24-161
|
|
162
|
SB24-162
|
|
163
|
SB24-163
|
|
164
|
SB24-164
|
|
165
|
SB24-165
|
|
166
|
SB24-166
|
|
167
|
SB24-167
|
|
168
|
SB24-168
|
|
169
|
SB24-169
|
|
170
|
SB24-170
|
