Blue Cross and Blue Shield Service Benefit Plan Brochure - 2025

FEHB FEP Blue Focus

 

Document list

Document Name Document Number
Cover Page FFBF25.00.1.1
Inside cover FFBF25.00.1.2
Table of Contents FFBF25.00.1.3
Introduction FFBF25.00.2.1
Plain Language FFBF25.00.2.2
Stop Healthcare Fraud FFBF25.00.2.3
Discrimination is Against the Law FFBF25.00.2.4
Preventing Medical Mistakes FFBF25.00.2.5
No pre-existing condition limitation FFBF25.00.3.1.1
Minimum essential coverage (MEC) FFBF25.00.3.1.2
Minimum value standard FFBF25.00.3.1.3
Where you can get information about enrolling in the FEHB Program FFBF25.00.3.1.4
Enrollment types available for you and your family FFBF25.00.3.1.5
Family member coverage FFBF25.00.3.1.6
Children's Equity Act FFBF25.00.3.1.7
When benefits and premiums start FFBF25.00.3.1.8
When you retire FFBF25.00.3.1.9
When FEHB coverage ends FFBF25.00.3.2.1
Upon divorce FFBF25.00.3.2.2
Temporary Continuation of Coverage (TCC) FFBF25.00.3.2.3
Finding replacement coverage FFBF25.00.3.2.4
Health Insurance Marketplace FFBF25.00.3.2.5
Section 1. How This Plan Works FFBF25.01.0
General features of FEP Blue Focus/We have a Preferred Provider Organization (PPO) FFBF25.01.1
How we pay professional and facility providers FFBF25.01.2
Your rights and responsibilities FFBF25.01.3
Your medical and claims records are confidential FFBF25.01.4
Section 2. Changes for 2025 FFBF25.02
Identification cards FFBF25.03.1
Where you get covered care FFBF25.03.2.0
Balance Billing Protection FFBF25.03.2.01
Covered professional providers FFBF25.03.2.1
Covered facility providers FFBF25.03.2.2
What you must do to get covered care FFBF25.03.3.0
Transitional care FFBF25.03.3.1
If you are hospitalized when your enrollment begins FFBF25.03.3.2
You need prior Plan approval for certain services FFBF25.03.4.00
Inpatient hospital admission, inpatient residential treatment center admission FFBF25.03.4.01
Other services FFBF25.03.4.02
Special prior authorization situations related to coordination of benefits (COB) FFBF25.03.4.03
Prior notification - Maternity care FFBF25.03.4.04
How to request precertification for an admission or get approval for Other services FFBF25.03.4.05
Non-urgent care claims FFBF25.03.4.06
Urgent care claims FFBF25.03.4.07
Concurrent care claims FFBF25.03.4.08
Emergency inpatient admission FFBF25.03.4.09
Maternity care FFBF25.03.4.10
If your facility stay needs to be extended FFBF25.03.4.11
If your treatment needs to be extended FFBF25.03.4.12
If you disagree with our pre-service claim decision FFBF25.03.5.0
To reconsider a non-urgent care claim FFBF25.03.5.1
To reconsider an urgent care claim FFBF25.03.5.2
To file an appeal with OPM FFBF25.03.5.3
Cost-share/Cost-sharing FFBF25.04.01
Copayment FFBF25.04.02
Deductible FFBF25.04.03
Coinsurance FFBF25.04.04
If your provider routinely waives your cost FFBF25.04.05
Waivers FFBF25.04.06
Differences between our allowance and the bill FFBF25.04.07
Important Notice About Surprise Billing – Know Your Rights FFBF25.04.08
Your costs for other care FFBF25.04.09
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments FFBF25.04.10
Carryover FFBF25.04.11
If we overpay you FFBF25.04.12
When Government facilities bill us FFBF25.04.13
The Federal Flexible Spending Account Program – FSAFEDS FFBF25.04.14
Section 5. Benefits - Table of Contents FFBF25.05.01
Section 5. FEP Blue Focus Overview FFBF25.05.02
Section 5(a). Overview FFBF25.05a.0
Diagnostic and Treatment Services FFBF25.05a.01
Lab, X-ray and Other Diagnostic Tests FFBF25.05a.02
Preventive Care, Adult FFBF25.05a.03
Preventive Care, Child FFBF25.05a.04
Maternity Care FFBF25.05a.05
Family Planning FFBF25.05a.06
Reproductive Services FFBF25.05a.07
Allergy Care FFBF25.05a.08
Treatment Therapies FFBF25.05a.09
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy FFBF25.05a.10
Hearing Services FFBF25.05a.11
Vision Services (Testing, Treatment, and Supplies) FFBF25.05a.12
Foot Care FFBF25.05a.13
Orthopedic and Prosthetic Devices FFBF25.05a.14
Durable Medical Equipment (DME) FFBF25.05a.15
Medical Supplies FFBF25.05a.16
Home Health Services FFBF25.05a.17
Alternative/Manipulative Treatment FFBF25.05a.18
Educational Classes and Programs FFBF25.05a.19
Section 5(b). Overview FFBF25.05b.0
Surgical Procedures FFBF25.05b.1
Reconstructive Surgery FFBF25.05b.2
Oral and Maxillofacial Surgery FFBF25.05b.3
Organ/Tissue Transplants FFBF25.05b.4
Anesthesia FFBF25.05b.5
Section 5(c). Overview FFBF25.05c.0
Inpatient Hospital FFBF25.05c.1
Maternity - Facility FFBF25.05c.2
Outpatient Hospital or Ambulatory Surgical Center FFBF25.05c.3
Residential Treatment Center FFBF25.05c.4
Document Name Document Number
Extended Care Benefits/Skilled Nursing Care Facility Benefits FFBF25.05c.5
Hospice Care FFBF25.05c.6
Ambulance FFBF25.05c.7
Section 5(d). Overview FFBF25.05d.0
Accidental Injury FFBF25.05d.1
Medical Emergency FFBF25.05d.2
Ambulance FFBF25.05d.3
Section 5(e). Overview FFBF25.05e.0
Professional Services FFBF25.05e.1
Inpatient Hospital or Other Covered Facility FFBF25.05e.2
Residential Treatment Center FFBF25.05e.3
Outpatient Hospital or Other Covered Facility FFBF25.05e.4
Section 5(f). Overview FFBF25.05f.0
There are important features you should be aware of FFBF25.05f.01
Who can write your prescriptions FFBF25.05f.02
Where you can obtain them FFBF25.05f.03
What is covered FFBF25.05f.04
Generic equivalents FFBF25.05f.05
Disclosure of information FFBF25.05f.06
These are the dispensing limitations FFBF25.05f.07
Patient Safety and Quality Monitoring (PSQM) FFBF25.05f.08
Prior Approval FFBF25.05f.09
Medical Foods FFBF25.05f.10
Here is how to obtain your prescription drugs and supplies FFBF25.05f.11
Preferred retail pharmacies FFBF25.05f.12
Section 5(f). MPDP Overview FFBF25.05f.13
MPDP There are important features you should be aware of FFBF25.05f.14
MPDP Who can write your prescriptions FFBF25.05f.15
MPDP Where you can obtain them FFBF25.05f.16
MPDP What is covered FFBF25.05f.17
MPDP Generic equivalents FFBF25.05f.18
MPDP Disclosure of information FFBF25.05f.19
MPDP These are the dispensing limitations FFBF25.05f.20
MPDP Important contact information FFBF25.05f.21
MPDP Prior Approval FFBF25.05f.22
MPDP Catastrophic Maximums FFBF25.05f.23
MPDP Medical Foods FFBF25.05f.24
MPDP Here is how to obtain your prescription drugs and supplies FFBF25.05f.25
MPDP Covered Drugs and Supplies FFBF25.05f.26
Over-the-counter (OTC) contraceptive drugs and devices FFBF25.05f.27
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network FFBF25.05f.28
Diabetic Meter Program FFBF25.05f.29
Medications to promote better health as recommended under the ACA FFBF25.05f.30
Generic medications to reduce breast cancer risk for women FFBF25.05f.31
Bowel preparation medications and antiretroviral therapy medications for HIV FFBF25.05f.32
Opioid Reversal Agents: Tier 1 medications including Narcan nasal spray and naloxone FFBF25.05f.33
Smoking and Tobacco Cessation Medications FFBF25.05f.34
Not Covered FFBF25.05f.35
Drugs From Other Sources FFBF25.05f.36
Section 5(g). Overview FFBF25.05g.0
Accidental Injury Benefit FFBF25.05g.1
Inpatient and Outpatient Facility Care FFBF25.05g.2
Health Tools FFBF25.05h.01
Services for the Deaf and Hearing Impaired FFBF25.05h.02
Web Accessibility for the Visually Impaired FFBF25.05h.03
Travel Benefit/Services Overseas FFBF25.05h.04
Healthy Families FFBF25.05h.05
Blue Health Assessment FFBF25.05h.06
Hypertension Management Program FFBF25.05h.07
MyBlue Customer eService FFBF25.05h.08
National Doctor & Hospital Finder FFBF25.05h.09
Care Management Programs FFBF25.05h.10
Flexible Benefits Option FFBF25.05h.11
Telehealth Services FFBF25.05h.12
Routine Annual Physical Incentive Program FFBF25.05h.13
The fepblue Mobile Application FFBF25.05h.14
Section 5(i). Services, Drugs, and Supplies Provided Overseas FFBF25.05i.0
Non-FEHB Benefits Available to Plan Members FFBF25.05N.0
Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover FFBF25.06
Section 7. Filing a Claim for Covered Services FFBF25.07
Section 8. The Disputed Claims Process FFBF25.08
When you have other health coverage FFBF25.09.1.0
TRICARE and CHAMPVA FFBF25.09.1.1
Workers' Compensation FFBF25.09.1.2
Medicaid FFBF25.09.1.3
When other Government agencies are responsible for your care FFBF25.09.2
When others are responsible for injuries FFBF25.09.3
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) FFBF25.09.4
Clinical trials FFBF25.09.5
When you have Medicare FFBF25.09.6.1
The Original Medicare Plan (Part A or Part B) FFBF25.09.6.2
Tell us about your Medicare coverage FFBF25.09.6.3
Private contract with your physician FFBF25.09.6.4
Medicare Advantage (Part C) FFBF25.09.6.5
Medicare prescription drug coverage (Part D) FFBF25.09.6.6
Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) FFBF25.09.6.6.1
Medicare prescription drug coverage (Part B) FFBF25.09.6.7
Primary payor chart FFBF25.09.6.8
When you are age 65 or over and do not have Medicare FFBF25.09.7
Physicians Who Opt-Out of Medicare FFBF25.09.8
When you have the Original Medicare Plan (Part A, Part B, or both) FFBF25.09.9
Cost-share when Medicare is your primary payor FFBF25.09.95
Section 10. Definitions of Terms We Use in This Brochure FFBF25.10
Index FFBF25.11
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus - 2025 FFBF25.12
2025 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan FFBF25.13
Document Name Document Number
Cover page FFBF25-000-1
Inside cover FFBF25-000-2
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