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.

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.

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.

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.

Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex, pregnancy or genetic information.

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 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, those who suffer from substance use disorders; 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), 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.

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/about-us/programs-initiatives/blue-distinction-specialty-care/centers-and-physicians-search; 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).

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.

Specialty care: You may continue seeing your specialist and receiving any PPO benefits for up to 90 days if you are undergoing treatment for a chronic or disabling condition and you 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
• we terminate our contract with your specialist for reasons other than for cause,

Contact us at the number on the back of your ID card 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.

Note: If you lose access to your specialist because you changed your carrier or plan option enrollment, contact your new plan.

Sex-Trait Modification: If you are mid-treatment under this Plan, within a surgical or chemical regimen for Sex-Trait Modification for diagnosed gender dysphoria, for services for which you received coverage under the 2025 Plan brochure, you may seek an exception to continue care for that treatment. If you have questions about the exception process, contact us using the customer service phone number listed on the back of your ID card. If you disagree with our decision on your exception, please see Section 8 of this brochure for the disputed claims process. Individuals under age 19 are not eligible for exceptions related to services for ongoing surgical or hormonal treatment for diagnosed gender dysphoria.

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.

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.

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.

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.

You do not need precertification in these cases:

• You are admitted to a hospital outside the United States; with the exception of 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.
• Medicare Part A is the primary payor for the hospital or skilled nursing facility stay.
  
  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.

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:

• Gene therapy and cellular immunotherapy, for example, CAR-T and T-Cell receptor therapy
• Medical benefit drugs – We require prior approval for certain drugs that will be submitted on a medical claim for reimbursement. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/medicalbenefitdrugs 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.
• Genetic testing - Prior approval for genetic testing is required when the test is being performed to assess the risk of passing a genetic condition to a child, or when the member has no active disease or signs or symptoms of the disease that is being screened. Prior approval is not required when a member has an active disease, signs and symptoms of a genetic condition that could be passed to a child, or when the test is needed to determine a course of treatment for a disease. If you are unsure whether your genetic test requires prior authorization, call the customer service number on the back of your ID card before scheduling.
• 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 elective non-urgent orthopedic procedures: hip, knee, and spine.
  • 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.
• 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.

• 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.

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.

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.

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).

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.

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.

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.

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 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 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 your claim is in reference to a contraceptive, call 800-624-5060.

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.

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.

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.

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 child
• 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: $50 copayment per visit

Note: You pay 35% 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: Copayments are waived for members with Medicare Part B primary.

Preferred Telehealth Provider: Nothing (no deductible)

Participating/Non-participating: You pay all charges

Preferred Telehealth Provider: Nothing

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
• 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.

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

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: 20% of the Plan allowance

Note: You pay 35% 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 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 35% 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 may be required; see Section 3)

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 35% 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.

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
• Ultrasound for abdominal aortic aneurysm for adults, ages 65 to 75, limited to a one-time screening
• Urinalysis

The following preventive services are covered at the time intervals recommended at each of the links below. Please also visit us at www.fepblue.org and type in "preventive care" for additional information about your preventive coverage.

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC) based on the Advisory Committee on Immunization Practices (ACIP) schedule such as COVID-19, Pneumococcal, influenza, shingles, tetanus/Tdap and human papillomavirus (HPV). For a complete list of immunizations, go to the website at https://www.cdc.gov/vaccines/imz-schedules/index.html.
  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.
• U.S. Preventive Services Task Force (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 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.hrsa.gov/womens-guidelines.
• 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.

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

Obesity counseling, screening and referral to intensive nutrition and behavioral weight-loss therapy, or counseling under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Unlimited nutritional counseling including nutritional counseling via the contracted telehealth provider network
• Unlimited visits for counseling on prevention and reducing health risks
• Unlimited visits for individual and group behavioral counseling for obesity
• Unlimited family-centered programs when medically identified to support obesity prevention and management by an in-network provider

Note: Benefits are available for anti-obesity medications. See Section 5(f).

Note: See Section 5(b) for information related to benefits for the surgical treatment of severe obesity.

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

Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.

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.
• 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 charges

All charges

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.
• Children's immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations, go to the website at https://www.cdc.gov/vaccines/imz-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.
• You may also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations 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.

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.

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.

See previous page

See previous page

Obesity counseling, screening and referral to intensive nutrition and behavioral weight-loss therapy, or counseling under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Unlimited nutritional counseling including nutritional counseling via the contracted telehealth provider network
• Unlimited visits for counseling on prevention and reducing health risks
• Unlimited visits for individual and group behavioral counseling for obesity
• Unlimited family-centered programs when medically identified to support obesity prevention and management by an in-network provider

Note: Benefits are available for anti-obesity medications. See Section 5(f).

Note: See Section 5(b) for information related to benefits for the surgical treatment of severe obesity.

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

Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.

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 noted above for nutritional counseling.

All charges

All charges

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 specialists for each birth
• 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.

Notes:

• 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.

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 $425 per admission. This copayment is waived if you deliver in a Blue Distinction Center for maternity. 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.

• 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 hospital stay, 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.

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)
• Tocolytic therapy and related services except as previously described
• Maternity care for members not enrolled in the Service Benefit Plan

A range of voluntary family planning services, without cost-sharing, that includes at least one form of contraception in each of the categories in the HRSA-supported guidelines. This list includes:

• Contraceptive counseling
• Diaphragms and contraceptive rings
• Injectable contraceptives
• Intrauterine devices (IUDs)
• Implantable contraceptives
• Salpingectomy
• Tubal ligation or tubal occlusion/tubal blocking procedures only
• Vasectomy
• Oral and transdermal contraceptives

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 including counseling and follow-up care at the payment levels shown here. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, and follow-up care). Any voluntary sterilization surgery that is not already available without cost-sharing can be accessed through the contraceptive exceptions process. Simply visit www.fepblue.org, type in family planning and look for the exception form under our voluntary family planning services, or you may call the number on the back of your ID card and request a form. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Note: When billed by a facility for any reason other than contraception, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Note: See additional Family Planning and Prescription drug coverage in Section 5(f).

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 they are being used for contraception. When used for other purposes, you pay the cost-share seen 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: 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: 35% 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)

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.

• Procurement of sperm or eggs including medical, surgical, and pharmacy claims associated with retrieval;
• Cryopreservation of sperm and mature oocytes; and
• Cryopreservation storage costs for one year.

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: 35% 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
• Services, supplies, or drugs provided to individuals not enrolled in this Plan, including surrogates

• 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: $50 copayment

Note: You pay 35% 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: $50 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 testing

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: $50 copayment per visit

Note: You pay 35% 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

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, 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: $50 copayment per visit

Note: You pay 35% 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

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

• 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: $50 copayment per visit

Note: You pay 35% 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) 

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: 35% of the Plan allowance

Participating/Non-participating: You pay all charges

• 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: $50 copayment per visit

Note: You pay 35% 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

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)

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: $50 copayment per visit

Note: You pay 35% 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

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
• 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: 35% 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.

• Bone-anchored hearing aids when medically necessary, limited to $5,000 per calendar year

• 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 one time.

Any amount over $350 for one wig one time (no deductible)

Any amount over $350 for one wig one time

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

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 prescribed 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: 35% of the Plan allowance

Participating/Non-participating: You pay all charges

• Speech-generating devices, limited to $1,250 per calendar 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

• 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: 35% 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
• Medical foods administered orally, except as described in Section 5(f)

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 35% 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

Manipulative treatment performed by a professional provider, when the provider is practicing within the scope of their 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

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.

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

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: $50 copayment per visit

Note: Benefits for acupuncture are limited to 12 visits per calendar year.

Note: You pay 35% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Not covered:

• Biofeedback
• Self-care or self-help training

• 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

• 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: $50 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

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
• Routine pre- and post-operative care by the surgeon
• Corneal transplants
• 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).

Note: For surgical family planning procedures, see Family Planning in Section 5(a).

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 35% 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

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 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)

• 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.

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) (See Section 5(d) for Accidental Injury benefits).
• Sex-Trait Modification: If you are mid-treatment under this Plan, within a surgical or chemical regimen for Sex-Trait Modification for diagnosed gender dysphoria, for services for which you received coverage under the 2025 Plan brochure, you may seek an exception to continue care for that treatment. If you have questions about the exception process, contact us using the customer service phone number listed on the back of your ID card. If you disagree with our decision, please see Section 8 of this brochure for the disputed claims process. Individuals under age 19 are not eligible for exceptions related to services for ongoing surgical or hormonal treatment for diagnosed gender dysphoria.

All charges

All charges

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

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: 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.

Continued from previous page:

Note: You pay 35% 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 charges

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

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.

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.

• 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

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

• 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

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

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

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 charges

All charges

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.

Notes:

• You do not need to precertify your delivery; see Section 3 for other circumstances, such as extended stays for you or your newborn.
• 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: $425 per day copayment up to $2,975 per admission

Note: Your responsibility for maternity care in a Preferred facility, or birthing center, is limited to a $425 copayment associated with the charges incurred during delivery. This copayment is waived if you deliver in a Blue Distinction Center for maternity.

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.
  • 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).

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
• 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: $250 copayment per day per facility

Note: You pay 35% 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: $425 per day copayment up to $2,975

Member/Non-member facilities: You pay all charges

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 may be required; see 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: $250 copayment per day per facility

Member facilities: $250 copayment per day per facility

Non-member facilities: $250 copayment per day per facility, plus any difference between our allowance and the billed amount

Note: You pay 35% 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: $75 copayment per day per facility

Member facilities: $75 copayment per day per facility

Non-member facilities: $75 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 35% 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 35% of the Plan allowance for agents or drugs administered or obtained in connection with your care.

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 35% 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: 20% of the Plan allowance

Member facilities: 20% of the Plan allowance

Non-member facilities: 20% 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 35% 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 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 one time 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: 35% 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

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.

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: $100 per day copayment up to $500 per admission

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.

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.

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: $425 per day copayment up to $2,975 per admission

Member/Non-member facilities: You pay all charges

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.

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 charges

All charges

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

All hospice services must be billed by an agency licensed as a hospice provider. 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, 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

Covered services

We provide benefits for the hospice services listed below:

• 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

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.

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 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.).

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.

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

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

$250 copayment per day for ground ambulance transport services

$750 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.

$250 copayment per day for ground ambulance transport services

$750 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

$250 copayment per day for ground ambulance transport services

$750 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.
• Costs associated with overseas air or sea transportation to other than the closest hospital equipped to adequately treat your condition.

• 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: $425 copayment per day per facility

Member emergency room: $425 copayment per day per facility

Non-member emergency room: $425 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 $425 emergency room copayment. However, the $425 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: $50 copayment per visit

Participating/Non-participating urgent care center: $50 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: $50 copayment per visit

Participating/Non-participating urgent care center: You pay all charges

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

• 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: $425 copayment per day per facility

Member emergency room: $425 copayment per day per facility

Non-member emergency room: $425 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 $425 emergency room copayment. However, the $425 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.

• 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: $50 copayment per visit

Participating/Non-participating urgent care center: $50 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: $50 copayment per visit

Participating/Non-participating urgent care center: You pay all charges

Not covered:  Emergency room professional charges for shift differentials

See Section 5(c) for complete ambulance benefit and coverage information.

See Section 5(c)

See Section 5(c)

We cover professional services by licensed professional mental health and substance use disorder practitioners when acting within the scope of their license.

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 per 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: Copayments are waived for members with Medicare Part B primary.

Preferred Telehealth provider: Nothing (no deductible)

Participating/Non-participating: You pay all charges

Preferred Telehealth provider: Nothing

Participating/Non-participating: You pay all charges

• 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 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: $425 per day copayment up to $2,975 per admission

Member/Non-member facilities: You pay all charges

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: $425 per day copayment up to $2,975 per admission

Member/Non-member facilities: You pay all charges

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: $425 per day copayment up to $2,975 per admission

Member/Non-member facilities: You pay all charges

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

• 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)
• 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

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 prescribed to treat obesity (prior approval required)
• Contraceptive drugs and devices, limited to:
  • Diaphragms and contraceptive rings
  • Injectable contraceptives
  • Intrauterine devices (IUDs)
  • Implantable contraceptives
  • Oral and transdermal contraceptives
• Medical foods

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 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): 35% of the Plan allowance ($150 maximum) for each purchase of up to a 30-day supply ($400 maximum for a 31 to 90-day supply)

Tier 3 (non-preferred brand-name drug): 60% of the Plan allowance for each purchase of up to a 90-day supply

Tier 4 (preferred specialty drug): 35% of the Plan allowance ($250 maximum) limited to one purchase of up to a 30-day supply

Tier 5 (non-preferred specialty drug): 35% of the Plan allowance ($500 maximum) 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)

• 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 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, as listed in each therapeutic class under the HRSA guidelines found at https://www.hrsa.gov/womens-guidelines, when purchased from a Preferred retail pharmacy. You may seek an exception for any contraceptive that is not available with zero-member cost-share. Your provider will need to complete the Contraceptive Exception Form under Pharmacy Forms found on our website at www.fepblue.org/claim-forms. If you have questions about the exception process, call 800-624-5060.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits, see Section 5(a).

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): 35% of the Plan allowance ($100 maximum) for each purchase of up to a 30-day supply ($300 maximum for a 31 to 90-day supply)

Tier 3 (non-preferred brand-name drug): 60% of the Plan allowance for up to a 90-day supply

Tier 4 (preferred specialty drug): 35% of the Plan allowance ($200 maximum) limited to one purchase of up to a 30-day supply

Tier 5 (non-preferred specialty drug): 35% of the Plan allowance ($450 maximum) limited to one purchase of up to a 30-day supply

Non-preferred Retail Pharmacies

45% 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.

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, as listed in each therapeutic class under the HRSA guidelines found at https://www.hrsa.gov/womens-guidelines, when purchased from a Preferred retail pharmacy. You may seek an exception for any contraceptive that is not available with zero-member cost-share. Your provider will need to complete the Contraceptive Exception Form under Pharmacy Forms found on our website at www.fepblue.org/claim-forms. If you have questions about the exception process, call 800-624-5060.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits, see Section 5(a).

Tier 1 (generic drug): $15 copayment (no deductible)

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.

Tier 2 (preferred brand-name drug): 15% of the Plan allowance (up to a $150 maximum) (no deductible)

Tier 3 (non-preferred brand-name drug) 20% of the Plan allowance (up to a maximum of $250) (no deductible)

When Medicare Part B is primary, you pay the following:

Tier 1 (generic drug): $20 copayment

Tier 2 (preferred brand-name drug): 35% of the Plan allowance up to a $225 maximum

Tier 3 (non-preferred brand-name drug): 35% of the Plan allowance up to a $250 maximum

When Medicare Part B is not primary: No benefits

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): $100 copayment for each purchase of up to a 30-day supply ($300 copayment for a 31 to 90-day supply) (no deductible)

Tier 5 (non-preferred specialty drug): $150 copayment for each purchase of up to a 30-day supply ($450 copayment for a 31 to 90-day supply) (no deductible)

Tier 4 (preferred specialty drug): 35% of the Plan allowance ($250 maximum) for each purchase of up to a 30-day supply ($700 maximum for a 31 to 90-day supply)

Tier 5 (non-preferred specialty drug): 35% of the Plan allowance ($500 maximum) for each purchase of up to a 30-day supply ($850 maximum for a 31 to 90-day supply)

When Medicare Part B is primary, you pay the following:

Tier 4 (preferred specialty drug): 35% of the Plan allowance ($200 maximum) for each purchase of up to a 30-day supply ($450 maximum for a 31 to 90-day supply)

Tier 5 (non-preferred specialty drug): 35% of the Plan allowance ($450 maximum) for each purchase of up to a 30-day supply ($625 maximum 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 2 (preferred controller medication): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply)

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)

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 drug): $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 drug): $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 drug): $50 copayment for each purchase of up to a 90-day supply

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

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
  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 prescribed to treat obesity (prior approval required)

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): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 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 for each purchase of up to a 90-day supply

• 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, as listed in each therapeutic class under the HRSA guidelines found at https://www.hrsa.gov/womens-guidelines, when purchased from a Preferred retail pharmacy. You may seek an exception for any contraceptive that is not available with zero-member cost-share. Your provider will need to complete the Contraceptive Exception Form under Pharmacy Forms found on our website at www.fepblue.org/claim-forms. If you have questions about the exception process, call 800-624-5060.

• 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, as

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

listed in each therapeutic class under the HRSA guidelines found at https://www.hrsa.gov/womens-guidelines, when purchased from a Preferred retail pharmacy. You may seek an exception for any contraceptive that is not available with zero-member cost-share. Your provider will need to complete the Contraceptive Exception Form under Pharmacy Forms found on our website at www.fepblue.org/claim-forms. If you have questions about the exception process, call 800-624-5060.

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.

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): $20 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply) (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): $20 copayment for each purchase of up to a 30-day supply ($50 copayment for a 31 to 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 drug): $50 copayment for each purchase of up to a 90-day supply

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

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, such as:
  • 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

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

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 rescue agents are covered under this Plan with no cost-sharing when obtained with a prescription from a pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

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:

For more information, consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose or call SAMHSA's National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.

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.

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

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
• 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 prescribed in connection with Sex-Trait Modification for treatment of gender dysphoria
  Note: If you are mid-treatment under this Plan, within a surgical or chemical regimen for Sex-Trait Modification for diagnosed gender dysphoria, for services for which you received coverage under the 2025 Plan brochure, you may seek an exception to continue care for that treatment. If you have questions about the exception process, contact us using the customer service phone number listed on the back of your ID card. If you disagree with our decision, please see Section 8 of this brochure for the disputed claims process. Individuals under age 19 are not eligible for exceptions related to services for ongoing surgical or hormonal treatment for diagnosed gender dysphoria.
• Drugs purchased through the mail or internet from pharmacies outside the United States by members located in the United States
• 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 charges

All charges

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 medical benefit drugs that will be submitted on a medical claim for reimbursement. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/medicalbenefitdrugs for a list of these drugs. See Section 3 for more information on prior approval.

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)

Preferred: 35% 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

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.

Continued from previous page:

Non-member facilities: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

See previous page

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

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

35% 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.

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

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 above

Nothing

Nothing

All charges

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 above

Nothing

All charges

• 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

• 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

• 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

• 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)