We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this Plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.

When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) – such as marriage, divorce, or the birth of a child – outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child or children.

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or Plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2022 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service), and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or family members are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31-day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (non-FEHB individual policy). FEP helps members with Temporary Continuation of Coverage (TCC) and with finding replacement coverage.

If you are divorced from a Federal employee or annuitant you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health benefits coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or TCC. If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM’s website, www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for TCC. The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, if you are a covered dependent child and you turn age 26, regardless of marital status, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB coverage.

We also want to inform you that the Patient Protection and ACA did not eliminate TCC or change the TCC rules.

If you would like to purchase health insurance through the Affordable Care Act’s Health Insurance Marketplace, please refer to the next Section of this brochure. We will help you find replacement coverage inside or outside the Marketplace. For assistance, please contact your Local Plan at the phone number appearing on the back of your ID card, or visit www.bcbs.com to access the website of your Local Plan.

Note: We do not determine who is eligible to purchase health benefits coverage inside the Affordable Care Act’s Health Insurance Marketplace. These rules are established by the Federal Government agencies that have responsibility for implementing the Affordable Care Act and by the Marketplace.

If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

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.

You must use those “covered professional providers” or “covered facility providers” that are Preferred providers for FEP Blue Focus in order to receive benefits. Benefits are not available for care from Non-preferred providers, except in very limited situations. Please refer to page 18 for the exceptions to this requirement. Refer to page 13 for more information about Preferred providers.

You can also get care for the treatment of minor acute conditions (see page 131 for definition), dermatology care (see page 39), and counseling for behavioral health and substance use disorder (see page 86), and nutritional counseling (see pages 41 and 44), using teleconsultation services delivered via phone by calling 855-636-1579, TTY: 855-636-1578, or via secure online video/messaging at www.fepblue.org/telehealth.

FEHB Carriers must have clauses in their in-network (participating) providers 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, coinsurance) 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.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require healthcare delivered by healthcare providers experienced in transgender health. While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall healthcare needs. Benefits described in this brochure are available to all members meeting medical necessity guidelines.

If you have questions about covered providers or would like the names of PPO (Preferred) providers, please contact the Local Plan where services will be performed.

Covered Preferred (PPO) 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, drug addicts, or alcoholics; or a custodial or domiciliary institution having as its primary purpose the furnishing of food, shelter, training, or non-medical personal services.

Note: You must use Preferred providers to receive benefits. 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-preferred (Member/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 accredited by a nationally recognized organization and licensed by the state, district, or territory 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. Benefits are available for services performed and billed by RTCs, as described on pages 76-77 and 87. If you have questions about treatment at an RTC, 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), Gene Therapy, 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.

Bariatric and Transplant care benefits are limited to services provided in a Blue Distinction Center. For more information, including the list of transplants that must be performed at a Blue Distinction Center see Section 5(b), pages 57 and 62.

For listings of Blue Distinction Centers, visit https://www.bcbs.com/blue-distinction-center/facility; 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.

Other facilities specifically listed in the benefits descriptions in Section 5(c).

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, 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 as an exception 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: If you have a chronic or disabling condition and

• 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
• lose access to your Preferred specialist because we terminate our contract with your specialist for reasons other than for cause,

you may be able to continue seeing your specialist and receiving any Preferred benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy 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.

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 ID card, you can contact your Local Plan at the phone number listed in your local phone directory. If you already have your new ID card, call us at the phone number on the back of your ID 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 or prior approval as required, there may be a reduction or denial of benefits. Be sure to read all of the precertification and prior approval information below and on pages 20-22. 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 or inpatient residential treatment center whether or not they have contacted us and provided all necessary information. You may also contact us at the phone number on the back of your ID card to ask if we have received the request for precertification. You are also responsible for enrolling in case management and working with your case manager if your care involves residential treatment. For information about precertification of an emergency inpatient hospital admission, please see page 26.

Note: Special rules apply when Medicare or another payer is primary, see pages 23-24.

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.

Note: If precertification was not obtained prior to admission, inpatient benefits (such as room and board) are not available for inpatient care at a residential treatment center. We will pay only 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 for gender reassignment surgery and admissions to residential treatment centers.

Note: Special rules apply when Medicare or another payer is primary, see pages 23-24.

You must obtain prior approval for these services in all outpatient and inpatient settings unless otherwise noted. Failure to obtain prior approval will result in a $100 penalty. Precertification is also required if the service or procedure requires an inpatient hospital admission. However, special rules apply when Medicare or another payer is primary, see pages 23-24. If an inpatient admission is necessary, precertification is also required. 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, including Car-T and T-cell receptor therapy
• Air Ambulance Transport (non-emergent) – Air ambulance transport related to immediate care of a medical emergency or accidental injury does not require prior approval; see Section 5(c), page 80, for more information.
• Applied behavior analysis (ABA) – Prior approval is required for ABA and all related services, including assessments, evaluations, and treatments.
• Genetic testing including the following:
  • BRCA screening or diagnostic testing
  • Large genomic rearrangements of the BRCA1 and BRCA2 genes screening or diagnostic testing
  • Genetic testing for the diagnosis and/or management of an existing medical condition

Note: Necessary medical evidence for BRCA related genetic testing includes the results of genetic counseling.

• Surgical services – The surgical services on the following list require prior approval and when care is provided in an inpatient setting, precertification is required for the hospital stay.
  • Procedures to treat morbid obesity (see page 57-58)
    
    Note: Benefits for the surgical treatment of morbid obesity – performed on an inpatient or outpatient basis – are subject to the pre-surgical requirements listed on page 58. Benefits are only available for the surgical treatment of morbid obesity when provided at a Blue Distinction Specialty Care Center for Bariatric (weight loss) surgery.
    
    Note: See pages 23-24 for special situations when another payor is primary.
  • Breast reduction or augmentation not related to treatment of cancer
  • Gender reassignment surgery – Prior to surgical treatment of gender dysphoria, your provider must submit a treatment plan including all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and your provider later modifies the plan.
    
    Note: See pages 23-24 for special situations when another payor is primary.
  • Surgical correction of congenital anomalies (see definition on page 129)
  • Oral maxillofacial surgeries/surgery on the jaw, cheeks, lips, tongue, roof and floor of the mouth, and related procedures
  • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
  • Orthopedic procedures: hip, knee, ankle, spine, shoulder and all orthopedic procedures using computer-assisted musculoskeletal surgical navigation
  • Reconstructive surgery for conditions other than breast cancer
  • Rhinoplasty
  • Septoplasty
  • Varicose vein treatment

• Intensity-modulated radiation therapy (IMRT) – Prior approval is required for all IMRT services except IMRT related to the treatment of head, neck, breast, prostate or anal cancer. Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is required for IMRT treatment of brain cancer.
• Hospice care – Prior approval is required for home hospice, continuous home hospice, or inpatient hospice care services. We will advise you which home hospice care agencies we have approved. See page 78 for information about the exception to this requirement.
• Cardiac rehabilitation
• Cochlear implants
• Residential treatment center care for any condition
  Note: See pages 23-24 for special situations when another payor is primary.
• Prosthetic devices (external), including: microprocessor controlled limb prosthesis; electronic and externally powered prosthesis
• Pulmonary rehabilitation
• Radiology, high technology including:
  • Magnetic resonance imaging (MRI)
  • Computed tomography (CT) scan
  • Positron emission tomography (PET) scan

Note: High technology radiology related to immediate care of a medical emergency or accidental injury does not require prior approval.

• Specialty durable medical equipment (DME), rental or purchase, to include:
  • Specialty hospital beds
  • Deluxe wheelchairs, power wheelchairs and mobility devices and related supplies

• Transplants: Prior Approval is required for all transplants, except cornea and kidney. Prior approval is required for both the procedure and if benefits require, the transplant program; precertification is required for inpatient care.
• Blood or marrow stem cell transplants listed on pages 63-65 must be performed in a transplant program designated as a Blue Distinction Center for Transplants. See page 17 for more information about these types of programs.
  
  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 transplant program is specifically designated as a Blue Distinction Center for Transplants for that procedure. Before scheduling a transplant, call your Local Plan at the customer service phone number appearing 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 – See pages 64-65 for 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 Blue Distinction Center for Transplants where the procedure is to be performed.

• Organ/tissue transplants
  Benefits for certain transplants are limited to designated transplant centers or programs.
  
  Transplants listed on page 66 must be performed in a transplant program designated as a Blue Distinction Center for Transplants.
  
  The organ transplants listed on page 66 are not available in a Blue Distinction Center for Transplants and must be performed at a Preferred facility with a Medicare-Approved Transplant Program, if one is available.

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 Preferred facility and Preferred provider that performs the procedure.

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. Our review will include whether you meet the facility and transplant program criteria for the particular transplant.

All members (including those who have Medicare Part A or another group health insurance policy as their primary payor) must contact us at the customer service phone number listed on the back of their ID card before obtaining services.

• Transplant travel – If you travel to a Blue Distinction Center for Transplants, we reimburse up to $5,000 per transplant for costs of transportation (air, rail, bus, and/or taxi) and lodging (for you and your traveling companions) if you live 50 miles or more from the facility.
• Prescription drugs and supplies – Certain prescription drugs and supplies, including medical foods administered orally (see pages 94 and 131), require prior approval. Contact CVS Caremark, our Pharmacy Program administrator, at 800-624-5060, TTY: 800-624-5077, 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 page 92 for more information about our prescription drug prior approval program, which is part of our Patient Safety and Quality Monitoring (PSQM) program.
  
  Notes:
  • Updates are made periodically throughout the year to the list of drugs and supplies requiring prior approval. 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.
  • 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 – and submit the expense(s) to us on a claim form. Preferred pharmacies will not file these claims for you.
  • The Specialty Drug Pharmacy Program will not fill your prescription 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 returned to you along with a letter explaining the prior approval procedures.

We will reduce our benefits by $100 for medically necessary services that require prior approval, if no one contacts us for prior approval. If the service is not medically necessary, we will not provide benefits. This benefit reduction does not apply to prescription drugs that require prior approval, see page 22.

The table below provides the special situations regarding prior approval and precertification when Medicare is the primary payor.

Service Type: Inpatient hospital admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Not applicable

Service Type: Medicare hospital benefits exhausted and you do not want to use your Medicare lifetime reserve days
Primary Payor: Medicare Part A benefits not provided
Precertification: Yes
Prior Approval: Not applicable

Service Type: Gender reassignment surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Yes

Service Type: Gender reassignment surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes

Service Type: Morbid obesity surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Yes

Service Type: Morbid obesity surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes

Service Type: Residential treatment center admission – inpatient
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Not applicable

Service Type: Residential treatment center – outpatient care
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes

The table below provides the special situations regarding prior approval and precertification when another healthcare insurance is the primary payor.

Service Type: Inpatient hospital admission
Primary Payor: Other healthcare insurance
Precertification: No
Prior Approval: Not applicable

Service Type: Gender reassignment surgery when performed during an inpatient admission
Primary Payor: Other healthcare insurance
Precertification: Yes
Prior Approval: Yes

Service Type: Gender reassignment surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Other healthcare insurance
Precertification: Not applicable
Prior Approval: Yes

Service Type: Morbid obesity surgery when performed during an inpatient admission
Primary Payor: Other healthcare insurance
Precertification: No
Prior Approval: Yes

Service Type: Morbid obesity surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Other healthcare insurance
Precertification: Not applicable
Prior Approval: Yes

Service Type: Residential treatment center admission – inpatient
Primary Payor: Other healthcare insurance
Precertification: Yes
Prior Approval: Not applicable

Service Type: Residential treatment center – outpatient care
Primary Payor: Other healthcare insurance
Precertification: Not applicable
Prior Approval: Yes

We encourage you to notify us of your pregnancy during the first trimester. Please contact us at the phone number on the back of your ID card and provide the following information:

• Enrollee’s name and Plan identification number
• Expected delivery date
• Date of your first prenatal appointment
• Name and phone number of the provider (i.e., physician, nurse practitioner, nurse midwife) providing your prenatal, delivery, and postnatal care
• Name and location of the place you intend to deliver (i.e., hospital, birthing center, your home)
• If you plan to deliver in a hospital, the type of delivery and the estimated number of days you will be in the hospital.

We will advise you if any additional information is needed.

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 ID card any time prior to admission or before receiving services that require prior approval with 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;
• Any other information we may request related to the services to be provided; and
• If the admission is to a residential treatment center (RTC), a preliminary treatment and discharge plan agreed to by the member, provider and case manager at the Local Plan, and the RTC.
  
  Note: You must enroll and participate in case management with your Local Plan prior to, during, and following an inpatient RTC stay. See pages 76-77 and 87 for additional information.

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 on page 26. 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 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 on this page below.

Admissions to residential treatment centers do not qualify as emergencies.

We encourage you to notify us of your pregnancy during the first trimester. 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 confinement, 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 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 your residential treatment center stay needs to be extended, you, your representative, your physician or the residential treatment center must ask us to approve the additional days. If you remain in the residential treatment center beyond the number of days approved and did not get the additional days precertified, we will provide benefits for medically necessary covered services, other than room and board and inpatient physician care, at the level we would have paid if they had been provided on an outpatient basis. Note: Benefits for inpatient residential treatment centers (RTCs) are limited to 30 days per calendar year.

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 on the next page. Note that these procedures apply to requests for reconsideration of concurrent care claims as well (see page 128 for definition). 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.

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.

Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).

FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Cost-share or cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Note: You may have to pay the deductible, coinsurance, and/or copayment amount(s) that apply to your care at the time you receive the services.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your Preferred professional provider for physical therapy, you pay a copayment of $25 for the visit, and we then pay the remainder of the amount we allow for the visit. (You may have to pay separately for other services you receive while in the provider’s office.)

Copayments do not apply to services and supplies that are subject to a deductible and/or coinsurance amount.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than your copayment, you pay the lower amount.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments and coinsurance amounts do not count toward your deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply that you then pay counts toward meeting your deductible.

The calendar year deductible is $500 per person. After the deductible amount is satisfied for an individual, covered services are payable for that individual. Under a Self Plus One enrollment, both family members must meet the individual deductible. Under a Self and Family enrollment, an individual may meet the individual deductible, or all family members’ individual deductibles are considered to be satisfied when the family members’ deductibles are combined and reach $1,000.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the remaining portion of your deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your calendar year deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of your $500 calendar year deductible has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan is after January 1 of the next year, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

Coinsurance is the percentage of the Plan allowance that you must pay for your care. Your coinsurance is based on the Plan allowance, or billed amount, whichever is less. Coinsurance does not begin until you have met your calendar year deductible.

Example: You pay 30% of the Plan allowance for durable medical equipment obtained from a Preferred provider, after meeting your $500 calendar year deductible.

If your provider routinely waives (does not require you to pay) your applicable copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

Example: If your physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49 (70% of the actual charge of $70).

In some instances, a provider may ask you to sign a “waiver” prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that the Local Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at the customer service phone number on the back of your ID card.

Our “Plan allowance” is the amount we use to calculate our payment for certain types of covered services. Fee-for-service plans arrive at their allowances in different ways, so allowances vary. For information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.

Often, the provider’s bill is more than a fee-for-service Plan’s allowance. It is possible for a provider’s bill to exceed the Plan’s allowance by a significant amount. Whether or not you have to pay the difference between our allowance and the bill will depend on the type of provider you use. Providers that have agreements with this Plan are Preferred and will not bill you for any balances that are in excess of our allowance for covered services. See the descriptions appearing below for the types of providers available in this Plan.

• Preferred providers. These types of providers have agreements with the Local Plan to limit what they bill our members. Because of that, when you use a Preferred provider, your share of the provider’s bill for covered care is limited.
  
  Your share consists only of your deductible, coinsurance, and/or copayment. Here is an example about coinsurance: You see a Preferred physician who charges $250, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just 30% of our $100 allowance ($30). Because of the agreement, your Preferred physician will not bill you for the $150 difference between our allowance and his/her bill.

Remember, you must use Preferred providers in order to receive benefits. See page 18 for the exceptions to this requirement.

• Non-preferred Providers:
  • Participating provider/Member facility. There are no benefits for care performed by Participating providers; you pay all charges. See page 18 for the exceptions to this requirement.
  • Non-participating providers/Non-member facility. There are no benefits for care performed by Non-participating providers; you pay all charges. See page 18 for the exceptions to this requirement.
    
    You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a Non-participating healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from Non-participating providers.

Balance billing happens when you receive a bill from the non-participating provider, facility, or air ambulance service for the difference between the Non-participating provider’s charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.fepblue.org/NSA or contact the customer service phone number on the back of your ID card.

Overseas care: Services provided outside the United States, Puerto Rico, and the U.S. Virgin Islands are considered overseas care. We pay overseas claims at Preferred benefit levels, so the requirement to use Preferred providers in order to receive benefits does not apply. See Section 5(i) for specific information about our overseas benefits.

Inpatient facility care: You must use Preferred facilities in order to receive benefits. See page 18 for the exceptions to this requirement.

We limit your annual out-of-pocket expenses for the covered services you receive to protect you from unexpected healthcare costs. When your eligible out-of-pocket expenses reach this catastrophic protection maximum, you no longer have to pay the associated cost-sharing amounts for the rest of the calendar year. For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.

Note: Certain types of expenses do not accumulate to the maximum.

Preferred Provider maximum – For a Self Only enrollment, your out-of-pocket maximum for your deductible, and for eligible coinsurance and copayment amounts, is $8,500 when you use Preferred providers. For a Self Plus One or a Self and Family enrollment, your out-of-pocket maximum for these types of expenses is $17,000 for Preferred provider services. Only eligible expenses for Preferred provider services count toward these limits.

The following expenses are not included under this feature. These expenses do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay them even after your expenses exceed the limits described above.

• The difference between the Plan allowance and the billed amount. See page 29;
• Expenses for services, drugs, and supplies in excess of our maximum benefit limitations;
• The $500 penalty for failing to obtain precertification, and any other amounts you pay because we reduce benefits for not complying with our cost containment requirements;
• The $100 penalty for failing to obtain prior approval, and any other amounts you pay because we reduce benefits for not complying with our cost containment requirements;
• If there is a generic substitution available and you or your provider requests a brand-name drug, your expenses for the difference between the cost of the generic medication and the brand-name medication do not count toward your catastrophic protection out-of-pocket maximum (see page 91 for additional information); and
• Expenses for care received from Non-preferred providers (Participating/Non-participating professional providers or Member/Non-member facilities), except for your deductible, coinsurance and/or copayments you pay in those situations where we do pay for care provided by Non-preferred providers. Please see page 18 for the exceptions to the requirement to use Preferred providers.

If you change to another plan during Open Season, we will continue to provide benefits between January 1 and the effective date of your new plan.

• If you had already paid the out-of-pocket maximum, we will continue to provide benefits as described above until the effective date of your new plan.
• If you had not yet paid the out-of-pocket maximum, we will apply any expenses you incur in January (before the effective date of your new plan) to our prior year’s out-of-pocket maximum. Once you reach the maximum, you do not need to pay our deductibles, copayments, or coinsurance amounts (except as shown above) from that point until the effective date of your new plan.

Because benefit changes are effective January 1, we will apply our next year’s benefits to any expenses you incur in January.

If you change options in this Service Benefit Plan during the year, we will credit the amounts already accumulated toward the catastrophic protection out-of-pocket limit of your old option to the catastrophic protection out-of-pocket limit of your new option. If you change from Self Only to Self Plus One or Self and Family, or vice versa, during the calendar year, please call us about your out-of-pocket accumulations and how they carry over.

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

We will generally first seek recovery from the provider if we paid the provider directly, or from the person (covered family member, guardian, custodial parent, etc.) to whom we sent our payment.

If we provided coverage in error, but in good faith, for prescription drugs purchased through one of our pharmacy programs, we will request reimbursement from the contract holder.

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

Stay connected to your health and get the answers you need when you need them by using Health Tools 24 hours a day, 365 days a year. Go to www.fepblue.org or call 888-258-3432 toll-free to check out these valuable easy-to-use services:

• Talk directly with a Registered Nurse any time of the day or night via phone, secure email, or live chat. Ask questions and get medical advice. Please keep in mind that benefits for any healthcare services you may seek after using Health Tools are subject to the terms of your coverage under this Plan.
• Personal Health Record – Access your secure online personal health record for information such as the medications you’re taking, recent test results, and medical appointments. Update, store, and track health-related information at any time.
• Blue Health Assessment – An online health and lifestyle questionnaire (see below).
• Online Health Coach (OHC) – Manage your health proactively by setting and managing health goals, create a plan of care, track your progress, and pursue healthy activities. The OHC offers members a combination of guidance, support, and resources.
• Health Topics and WebMD Videos offer an extensive variety of educational tools using videos, recorded messages, and colorful online materials that provide up-to-date information about a wide range of health-related topics.

All Blue Cross and Blue Shield Plans provide TTY access for the hearing impaired to access information and receive answers to their questions.

Our website, www.fepblue.org, adheres to the most current Section 508 Web accessibility standards to ensure that visitors with visual impairments can use the site with ease.

Please refer to Section 5(i) for benefit and claims information for care you receive outside the United States, Puerto Rico, and the U.S. Virgin Islands.

Our Healthy Families suite of resources is for families with children and teens, ages 2 to 19. Healthy Families provides activities and tools to help parents teach their children about weight management, nutrition, physical activity, and personal well-being. For more information, go to www.fepblue.org.

The Blue Health Assessment (BHA) questionnaire is an easy and engaging online health evaluation program which can be completed in 10-15 minutes. Your BHA answers are evaluated to create a unique health action plan. Based on the results of your BHA, you can select personalized goals, receive supportive advice, and easily track your progress through our Online Health Coach.

Visit our website, www.fepblue.org, for more information and to complete the BHA so you can receive your individualized results and begin working toward achieving your goals. You may also request a printed BHA by calling 888-258-3432 toll-free.

The Hypertension Management Program gives members with hypertension (otherwise known as high blood pressure) access to a free blood pressure monitor (BPM) to encourage members to make healthier choices to reduce the potential for complications from cardiac disease.

To qualify, you must be the contract holder or covered spouse (age 18 and over) and have at least one medical claim processed during the past 12 months reporting a diagnosis of hypertension or high blood pressure. If you qualify, you will receive a letter and a notice will be sent to your MyBlue account (visit www.fepblue.org to set up your account) with instructions on how you may receive a blood pressure monitor from us at no cost if your healthcare provider’s treatment plan includes home blood pressure monitoring for your diagnosis. You may receive this benefit once every two years. If you have questions, please call the customer service phone number listed on the back of your ID card.

The BPM must be received through this program. Benefits are not available for BPMs for members who do not meet the criteria or for those who obtain a BPM outside of this program. For more information, call us at the phone number on the back of your ID card.

Visit MyBlue Customer eService at www.fepblue.org/myblue or use the fepblue mobile app to check the status of your claims, change your address of record, request claim forms, request an ID card, and track how you use your benefits. Additional features include:

• Online EOBs – You will automatically be enrolled in online EOBs. This will allow you to view, download, and print your explanation of benefits (EOB) forms. Simply log on to MyBlue via www.fepblue.org/myblue and click on “View My Claims”; from there you can search claims and select the “EOB” link next to each claim to access your EOB. Though your EOBs will be typically available online, there are some instances where you will receive a paper EOB and a form to complete. You can also access EOBs via the fepblue mobile app. Simply link to MyBlue, and click on Claims.
• Opt into Paper EOBs – If you wish to receive paper EOBs, you may Log on to MyBlue home page, click on “Member Preferences” from the navigation bar and opt in by selecting “paper EOBs.”
• Personalized Messages – Our EOBs provide a wide range of messages just for you and your family, ranging from preventive care opportunities to enhancements to our online services.
• Financial Dashboard – Log in to MyBlue to access important information in real time, including deductibles, out-of-pocket costs, remaining covered provider visits, medical claims, and pharmacy claims. You also can review your year-to-date summary of completed claims, and pharmacy spending throughout the year.

Visit www.fepblue.org/provider to access our National Doctor & Hospital Finder and other nationwide listings of Preferred providers.

If you have a rare or chronic disease or have complex healthcare needs, the Service Benefit Plan offers two types of Care Management Programs that provide assistance with the coordination of your care, provide member education and clinical support.

• Case Management provides members who have acute or chronic complex healthcare needs with the services and assistance of a licensed healthcare professional with a nationally recognized case management certification. Case managers may be a registered nurse, licensed social worker, or other licensed healthcare professional practicing within the scope of their license, who may work with you and your providers to assess your healthcare needs, coordinate needed care and available resources, evaluate the outcomes of your care, and support and monitor the progress of the member’s treatment plan and healthcare needs. Some members may receive guidance and clinical support for an acute healthcare need while others may benefit from a short term case management enrollment. Enrollment in case management requires your consent. Members in case management are asked to provide verbal consent prior to enrollment in case management and must provide written consent for case management.
  
  Note: Benefits for care provided by residential treatment centers require written consent and participation in Case Management prior to admission; please see pages 76, 87 and 107 for additional information.
• Disease Management supports members who have diabetes, asthma, chronic obstructive pulmonary disease (COPD), coronary artery disease, or congestive heart failure by helping them adopt effective self-care habits to improve the self-management of their condition. If you have been diagnosed with any of these conditions, we may send you information about the programs available to you in your area.

If you have any questions regarding these programs, including if you are eligible for enrollment and assistance with enrollment, please contact us at the customer service phone number on the back of your ID card.

Under the Blue Cross and Blue Shield Service Benefit Plan’s FEP Blue Focus, our Case Management process may include a flexible benefits option. This option allows professional case managers at Local Plans to assist members with certain complex and/or chronic health issues by coordinating complicated treatment plans and other types of complex patient care plans. Through the flexible benefits option, case managers will review the member’s healthcare needs and may at our sole discretion, identify a less costly alternative treatment plan for the member. The member (or their healthcare proxy) and provider(s) must cooperate in the process. Case Management Program enrollment is required for eligibility. Prior to the starting date of the alternative treatment plan, members who are eligible to receive services through the flexible benefits option are required to sign and return a written consent for case management and the alternative plan. If you and your provider agree with the plan, alternative benefits will begin immediately and you will be asked to sign an alternative benefits agreement that includes the terms listed below, in addition to any other terms specified in the agreement. We must receive the consent for case management and the alternative benefits agreement signed by the member/healthcare proxy before you receive any services included in the alternative benefits agreement.

• Alternative benefits will be made available for a limited period of time and are subject to our ongoing review. You must cooperate with and participate in the review process. Your provider(s) must submit the information necessary for our reviews. You and/or your healthcare proxy must participate in care conferences and caregiver training as requested by your provider(s) or by us.
• We may revoke the alternative benefits agreement immediately at any time, if we discover we were misled by the information given to us by you, your provider, or anyone else involved in your care, or that you are not meeting the terms of the agreement.
• If we approve alternative benefits, we do not guarantee that they will be extended beyond the limited time period and/or scope of the alternative benefits agreement or that they will be approved in the future.
• The decision to offer alternative benefits is solely ours, and unless otherwise specified in the alternative benefits agreement, we may at our sole discretion, withdraw those benefits at any time and resume regular contract benefits.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

If you sign the alternative benefits agreement, we will provide the agreed-upon alternative benefits for the stated time period, unless we are misled by the information given to us or circumstances change. Benefits as stated in this brochure will apply to all services and dates of care not included in the alternative benefits agreement. You or your provider may request an extension of the time period initially approved for alternative benefits, no later than five business days prior to the end of the alternative benefits agreement. We will review the request, including the services proposed as an alternative and the cost of those services, but benefits as stated in this brochure will apply if we do not approve your request.

Note: If we deny a request for precertification or prior approval of regular contract benefits, as stated in this brochure, or if we deny regular contract benefits for services you have already received, you may dispute our denial of regular contract benefits under the OPM disputed claims process (see Section 8).

Go to www.fepblue.org/telehealth or call 855-636-1579, TTY: 855-636-1578, toll free to access on-demand, affordable, high-quality care for adults and children experiencing non-emergency medical issues, including treatment of minor acute conditions (see page 131 for definition), dermatology care, counseling for mental health and substance use disorder, and nutritional counseling.

Note: This benefit is available only through the contracted telehealth provider network.

The Routine Annual Physical Incentive Program rewards members for receiving a routine annual physical exam. This incentive enables you to receive, at no cost, an incentive reward from our “shopping mall.” To qualify, you must be the contract holder or covered spouse (over age 18), receive an annual routine physical exam from a Preferred provider, and have an active MyBlue account (visit www.fepblue.org to set up your account). Qualifying members will receive notification through their MyBlue account with instructions on how to redeem this incentive. Additional details are available on our website, www.fepblue.org/fepbluefocus. FEP Blue Focus members may also call 800-411-BLUE (2583) for inquiries related to this incentive program.

Note: In order to receive your incentive, you must have received your annual physical no later than December 31, 2022, and you must request your incentive before December 31, 2023. Please allow ample time to complete all activities by this date. If these activities are not completed by the dates listed above, the incentive will be forfeited. Product availability and shipping limitations may apply. International shipping is not available.

Blue Cross and Blue Shield’s fepblue mobile application is available for download for both iOS and Android mobile phones. The application provides members with 24/7 access to helpful features, tools and information related to Blue Cross and Blue Shield Service Benefit Plan’s FEP Blue Focus benefits. Members can log in with their MyBlue^® username and password to access personal healthcare information such as benefits, out-of-pocket costs, deductibles (if applicable) and physician visit limits. They can also view claims and approval status, view/share Explanation of Benefits (EOBs), view/share member ID cards, locate Preferred providers, and connect with our telehealth services.

We have a network of participating hospitals overseas that will file your claims for inpatient facility care for you – without an advance payment for the covered services you receive. We also have a network of professional providers who have agreed to accept a negotiated amount as payment in full for their services. The Overseas Assistance Center can help you locate a hospital or physician in our network near where you are staying. You may also view a list of our network providers on our website, www.fepblue.org. You will have to file a claim to us for reimbursement for professional services unless you or your provider contacts the Overseas Assistance Center in advance to arrange direct billing and payment to the provider.

If you are overseas and need assistance locating providers (whether in or out of our network), contact the Overseas Assistance Center (provided by GMMI), by calling 804-673-1678. Members in the United States, Puerto Rico, or the U.S. Virgin Islands should call 800-699-4337 or email the Overseas Assistance Center at fepoverseas@gmmi.com. GMMI also offers emergency evacuation services to the nearest facility equipped to adequately treat your condition, translation services, and conversion of foreign medical bills to U.S. currency. You may contact one of their multilingual operators
24 hours a day, 365 days a year.

For professional care you receive overseas, we provide benefits at Preferred benefit levels using either our Overseas Fee Schedule, a customary percentage of the billed charge, or a provider-negotiated discount as our Plan allowance. The requirement to use Preferred providers in order to receive benefits does not apply when you receive overseas care.

When the Plan allowance is based on the Overseas Fee Schedule, you pay any difference between our payment and the amount billed, in addition to any applicable deductible, coinsurance and/or copayment amounts. When the Plan allowance is a provider-negotiated discount, you are only responsible for any applicable deductible, coinsurance and/or copayment. You must also pay any charges for noncovered services.

For inpatient facility care you receive overseas, we provide benefits at the Preferred level without member cost-share, for admissions to a DoD facility, or when the Overseas Assistance Center (provided by GMMI) has arranged direct billing or acceptance of a guarantee of benefits with the facility. For all other inpatient facility care, you are responsible for any applicable deductible and coinsurance.

For outpatient facility care you receive overseas, we provide benefits at the Preferred level after you pay the applicable deductible, copayment and/or coinsurance.

For transport services you receive overseas, we provide benefits for transport services to the nearest hospital equipped to adequately treat your condition when the transport services are medically necessary. We provide benefits as described in Section 5(c) and Section 5(d). Benefits are not available for costs associated with transportation to other than the closest hospital equipped to treat your condition. You are responsible for any deductible and coinsurance and/or copayments. You must also pay any charges for noncovered services.

For prescription drugs purchased at overseas pharmacies, we provide benefits at Preferred benefit levels, using the billed charge as our Plan allowance. You pay the applicable copayment or coinsurance. The calendar year deductible is not applicable when purchasing drugs at pharmacies located overseas. See page 93 in Section 5(f) for more information.

Most overseas providers are under no obligation to file claims on behalf of our members. Follow the procedures listed below to file claims for covered services and drugs you receive outside the United States, Puerto Rico, and the U.S. Virgin Islands. You may need to pay for the services at the time you receive them and then send a claim to us for reimbursement. We will provide translation and currency conversion services for your overseas claims.

To file a claim for covered hospital and professional provider services received outside the United States, Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Overseas Medical Claim Form, by mail, fax, or internet, along with itemized bills from the provider. In completing the claim form, indicate whether you want to be paid in U.S. dollars or in the currency reflected on the itemized bills, and if you want to receive payment by check or bank wire. Use the following information to mail, fax, or submit your claim electronically:

1. Mail: Federal Employee Program, Overseas Claims, P.O. Box 260070, Pembroke Pines, FL 33026.
2. Fax: 001-954-308-3957. Be sure to first dial the AT&T Direct Access Code of the country from which you are faxing the claim.
3. Internet: Go to the MyBlue portal on www.fepblue.org. If you are already a registered MyBlue portal user, click on the “Health Tools” menu and, in the “Get Care” section, select “Submit Overseas Claim” and follow the instructions for submitting a medical claim. If you are not yet a registered user, go to MyBlue, click on the “Sign Up” link, and register to use the online filing process.

If you have questions about your medical claims, call us at 888-999-9862, using the AT&T Direct Access Code of the country from which you are calling, or email us through our website (www.fepblue.org) via the MyBlue portal. You may also write to us at: Mailroom Administrator, FEP Overseas Claims, P.O. Box 14112, Lexington, KY 40512-4112. You may obtain Overseas Medical Claim Forms from our website, by email at fepoverseas@gmmi.com or from your Local Plan.

Drugs purchased overseas must be the equivalent to drugs that by Federal law of the United States require a prescription. To file a claim for covered drugs and supplies you purchase from pharmacies outside the United States, Puerto Rico, and the U.S. Virgin Islands, send us a completed FEP Retail Prescription Drug Overseas Claim Form, along with itemized pharmacy receipts or bills. The timely filing deadline for overseas pharmacy claims is limited to one year from the prescription fill date. Use the following information to mail, fax, or submit your claim electronically:

1. Mail: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.
2. Fax: 001-480-614-7674. Be sure to first dial the AT&T Direct Access Code of the country from which you are faxing the claim.
3. Internet: Go to the MyBlue portal on www.fepblue.org. If you are already a registered MyBlue portal user, click on the “Health Tools” menu and, in the “Get Care” section, select “Submit Overseas Claim” and follow the instructions for submitting a pharmacy claim. If you are not yet a registered user, go to MyBlue, click on the “Sign Up” link, and register to use the online filing process.

Send any written inquiries concerning drugs you purchase overseas to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057. You may obtain FEP Retail Prescription Drug Overseas Claim forms for your drug purchases by visiting our website, www.fepblue.org, by writing to the address above, or by calling us at 888-999-9862, using the AT&T Direct Access Code of the country from which you are calling.

While overseas, you may be able to order your prescription drugs through our Specialty Drug Pharmacy Program as long as all of the following conditions are met:

• Your address includes a U.S. ZIP code (such as with APO and FPO addresses and in U.S. territories),
• The prescribing physician is licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, and has a National Provider Identifier (NPI), and
• Delivery of the prescription is permitted by law and is in accordance with the manufacturer’s guidelines.

See Section 5(f) for more information about Preferred retail pharmacies with online ordering and delivery options, and the Specialty Drug Pharmacy Program.

Note: In most cases, temperature-sensitive drugs cannot be sent to APO/FPO addresses due to the special handling they require.

Note: We are unable to ship drugs, through our Specialty Drug Pharmacy Program, to overseas countries that have laws restricting the importation of prescription drugs from any other country. This is the case even when a valid APO or FPO address is available. If you are living in such a country, you may obtain your prescription drugs from a local overseas pharmacy and submit a claim to us for reimbursement by faxing it to 001-480-614-7674 or filing it via our website at www.fepblue.org/myblue.

To obtain claim forms or other claims filing advice, or answers to your questions about our benefits, contact us at the customer service phone number on the back of your ID card, or at our website at www.fepblue.org.

In most cases, physicians and facilities file claims for you. Just present your ID card when you receive services. Your provider must file on the CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form.

When you must file a claim – such as when another group health plan is primary – submit it on the CMS-1500 or a claim form that includes the information shown below. Use a separate claim form for each family member. For long or continuing inpatient stays, or other long-term care, you should submit claims at least every 30 days. Bills and receipts should be itemized and show:

• Patient’s name, date of birth, address, phone number, and relationship to enrollee
• Patient’s Plan identification number
• Name and address of person or company providing the service or supply
• Dates that services or supplies were furnished
• Diagnosis
• Type of each service or supply
• Charge for each service or supply

Note: Canceled checks, cash register receipts, balance due statements, or bills you prepare yourself are not acceptable substitutes for itemized bills.

In addition:

• If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) form you received from your primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
• If your claim is for the rental or purchase of durable medical equipment, home nursing care, or physical, occupational, speech, or cognitive rehabilitation therapy, you must provide a written statement from the provider specifying the medical necessity for the service or supply and the length of time needed.
• Claims for dental care to repair accidental injury to sound natural teeth should include 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.

Claims for prescription drugs and supplies that are not received from the Retail Pharmacy Program must include receipts that show the prescription number, name of drug or supply, prescribing provider’s name, date, and charge. (See pages 97-99 for information on how to obtain benefits from the Retail Pharmacy Program and the Specialty Drug Pharmacy Program.)

We will notify you of our decision within 30 days after we receive your post-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 before the expiration of the original 30-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 (e.g., medical records) 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 do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Preferred Retail Pharmacies – When you use Preferred retail pharmacies, show your ID card. To find a Preferred retail pharmacy, visit www.fepblue.org/provider. If you use a Preferred retail pharmacy that offers online ordering, have your ID card ready to complete your purchase. Preferred retail pharmacies file your claims for you. We reimburse them for your covered drugs and supplies. You pay the applicable coinsurance or copayment.

Note: Even if you use Preferred retail pharmacies, you will have to file a paper claim form to obtain reimbursement if:

• You do not have a valid ID card;
• You do not use your valid ID card at the time of purchase; or
• You did not obtain prior approval when required (see page 22).

See the following paragraphs for claim filing instructions.

Non-Preferred Retail Pharmacies: There are no benefits for drugs or supplies purchased at Non-preferred retail pharmacies. Note: For overseas pharmacy, see page 108.

Specialty Drug Pharmacy Program

If your physician prescribes a specialty drug that appears on our FEP Blue Focus Specialty Drug List, your physician may order the initial prescription by calling our Specialty Drug Pharmacy Program at 888-346-3731, TTY: 877-853-9549, or you may send your prescription to: BCBS FEP Specialty Drug Pharmacy Program, CVS Specialty, 9310 Southpark Center Loop, Orlando, FL 32819. You will be billed later for the copayment. The Specialty Drug Pharmacy Program will work with you to arrange a delivery time and location that is most convenient for you. To order refills, call the same phone number to arrange your delivery. You may either charge your copayment to your credit card or have it billed to you later.

Note: For the most up-to-date listing of covered specialty drugs, call the Specialty Drug Pharmacy Program at 888-346-3731, TTY: 877-853-9549, or visit our website, www.fepblue.org.

Keep a separate record of the medical expenses of each covered family member, because deductibles and benefit maximums (such as those for outpatient physical therapy) apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.

Send us your claim and appropriate documentation as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided you submitted the claim as soon as reasonably possible. If we return a claim or part of a claim for additional information (e.g., diagnosis codes, dates of service, etc.), you must resubmit it within 90 days, or before the timely filing period expires, whichever is later.

Note: Timely filing for overseas pharmacy claims is limited to one year from the prescription fill date.

Note: Once we pay benefits, there is a five-year limitation on the re-issuance of uncashed checks.

Please refer to the claims filing information on page 108 of this brochure.

Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. For the purposes of this Section, we are also referring to your authorized representative when we refer to you.

The Secretary of Health and Human Services has identified counties where at least 10 percent of the population is literate only in certain non-English languages. The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo, and Tagalog. If you live in one of these counties, we will provide language assistance in the applicable non-English language. You can request a copy of your explanation of benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the procedure or treatment code and its corresponding meaning.

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at the address shown on your explanation of benefits (EOB) form for the Local Plan that processed the claim (or, for Prescription drug benefits, our Retail Pharmacy Program or the Specialty Drug Pharmacy Program); and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in
Step 3.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

c) 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.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us – if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information – if we did not send you a decision within 30 days after we received the additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 1, 1900 E Street NW, Washington, DC 20415-3610.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians’ letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim;
• Your daytime phone number and the best time to call; and
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies, or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claims decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other group health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For example:

• If you are covered under our Plan as a dependent, any group health insurance you have from your employer will pay primary and we will pay secondary.
• If you are an annuitant under our Plan and also are actively employed, any group health insurance you have from your employer will pay primary and we will pay secondary.
• When you are entitled to the payment of healthcare expenses under automobile insurance, including no-fault insurance and other insurance that pays without regard to fault, your automobile insurance is the primary payor and we are the secondary payor.

For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.fepblue.org/coordinationofbenefits.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. For example, we will generally only make up the difference between the primary payor’s benefits payment and 100% of the Plan allowance, subject to our applicable deductible and coinsurance or copayment amounts, except when Medicare is the primary payor (see page 124). Thus, it is possible that the combined payments from both plans may not equal the entire amount billed by the provider.

Note: When we pay secondary to primary coverage you have from a prepaid plan (HMO), we base our benefits on your out-of-pocket liability under the prepaid plan (generally, the prepaid plan’s copayments), subject to our deductible and coinsurance or copayment amounts.

In certain circumstances when we are secondary and there is no adverse effect on you (that is, you do not pay any more), we may also take advantage of any provider discount arrangements your primary plan may have and only make up the difference between the primary plan’s payment and the amount the provider has agreed to accept as payment in full from the primary plan.

Note: Any visit limitations that apply to your care under this Plan are still in effect when we are the secondary payor.

Remember: Even if you do not file a claim with your other plan, you must still tell us that you have double coverage, and you must also send us documents about your other coverage if we ask for them.

Please see Section 4, Your Costs for Covered Services, for more information about how we pay claims.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or a similar agency pays its maximum benefits for your treatment, we will cover your care.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

If another person or entity, through an act or omission, causes you to suffer an injury or illness, and if we paid benefits for that injury or illness, you must agree to the provisions listed below. In addition, if you are injured and no other person or entity is responsible but you receive (or are entitled to) a recovery from another source, and if we paid benefits for that injury, you must agree to the following provisions:

• All recoveries you or your representatives obtain (whether by lawsuit, settlement, insurance or benefit program claims, or otherwise), no matter how described or designated, must be used to reimburse us in full for benefits we paid. Our share of any recovery extends only to the amount of benefits we have paid or will pay to you, your representatives, and/or healthcare providers on your behalf. For purposes of this provision, “you” includes your covered dependents, and “your representatives” include, if applicable, your heirs, administrators, legal representatives, parents (if you are a minor), successors, or assignees. This is our right of recovery.
• We are entitled under our right of recovery to be reimbursed for our benefit payments even if you are not “made whole” for all of your damages in the recoveries that you receive. Our right of recovery is not subject to reduction for attorney’s fees and costs under the “common fund” or any other doctrine.
• We will not reduce our share of any recovery unless, in the exercise of our discretion, we agree in writing to a reduction (1) because you do not receive the full amount of damages that you claimed or (2) because you had to pay attorneys’ fees.
• You must cooperate in doing what is reasonably necessary to assist us with our right of recovery. You must not take any action that may prejudice our right of recovery.
• If you do not seek damages for your illness or injury, you must permit us to initiate recovery on your behalf (including the right to bring suit in your name). This is called subrogation.

If you do seek damages for your illness or injury, you must tell us promptly that you have made a claim against another party for a condition that we have paid or may pay benefits for, you must seek recovery of our benefit payments and liabilities, and you must tell us about any recoveries you obtain, whether in or out of court. We may seek a first priority lien on the proceeds of your claim in order to reimburse ourselves to the full amount of benefits we have paid or will pay.

We may request that you sign a reimbursement agreement and/or assign to us (1) your right to bring an action or (2) your right to the proceeds of a claim for your illness or injury. We may delay processing of your claims until you provide the signed reimbursement agreement and/or assignment, and we may enforce our right of recovery by offsetting future benefits.

Note: We will pay the costs of any covered services you receive that are in excess of any recoveries made.

Our rights of recovery and subrogation as described in this Section may be enforced, at the Carrier’s option, by the Carrier, by any of the Local Plans that administered the benefits paid in connection with the injury or illness at issue, or by any combination of these entities. Please be aware that more than one Local Plan may have a right of recovery/subrogation for claims arising from a single incident (e.g., a car accident resulting in claims paid by multiple Local Plans) and that the resolution by one Local Plan of its lien will not eliminate another Local Plan’s right of recovery.

Among the other situations covered by this provision, the circumstances in which we may subrogate or assert a right of recovery shall also include:

• When a third party injures you, for example, in an automobile accident or through medical malpractice;
• When you are injured on premises owned by a third party; or
• When you are injured and benefits are available to you or your dependent, under any law or under any type of insurance, including, but not limited to:
  • No-fault insurance and other insurance that pays without regard to fault, including personal injury protection benefits, regardless of any election made by you to treat those benefits as secondary to this Plan
  • Uninsured and underinsured motorist coverage
  • Workers’ Compensation benefits
  • Medical reimbursement coverage

Contact us if you need more information about subrogation.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one dental/vision plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan, you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

If you are a participant in an approved clinical trial, this health Plan will provide benefits for covered related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for medically necessary services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy. We provide benefits for these types of costs at the benefit levels described in Section 5 (Benefits) when the services are covered under the Plan and we determine that they are medically necessary.
• Extra care costs – costs of covered services related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. This Plan covers extra care costs related to taking part in an approved clinical trial for a covered stem cell transplant such as additional tests that a patient may need as part of the clinical trial protocol, but not as part of the patient’s routine care. For more information about approved clinical trials for covered stem cell transplants, see pages 64-65. Extra care costs related to taking part in any other type of clinical trial are not covered. We encourage you to contact us at the customer service phone number on the back of your ID card to discuss specific services if you participate in a clinical trial.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (U.S. FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

For more detailed information on “What is Medicare?” and “Should I enroll in Medicare?” please contact Medicare at 1-800-Medicare 800-633-4227, TTY: 877-486-2048, or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. For example, you must continue to obtain prior approval for some prescription drugs and organ/tissue transplants before we will pay benefits. However, you do not have to precertify inpatient hospital stays when Medicare Part A is primary (see page 19 for exceptions).

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When the Original Medicare Plan is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for the covered charges. To find out if you need to do something to file your claims, call us at the customer service phone number on the back of your ID card or visit our website at www.fepblue.org.

We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:

When Medicare Part A is primary –

• We will waive our calendar year deductible and coinsurance
• Once you have exhausted your Medicare Part A benefits, you must then pay the coinsurance once the calendar year deductible has been satisfied for the inpatient admission.
  
  Note: Precertification is required.

When Medicare Part B is primary –

• We will waive our calendar year deductible, coinsurance and copayments for inpatient and outpatient services and supplies provided by physicians and other covered healthcare professional and outpatient facility services.

Note: We do not waive benefit limitations, such as the 10-visit limit for home skilled nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.

You can find more information about how our Plan coordinates benefits with Medicare in our Medicare and You Guide for Federal Employees available online at www.fepblue.org.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare’s payment. You may be responsible for paying the difference between the billed amount and the amount we paid.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), TTY: 877-486-2048, or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB Plan. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

We provide benefits for care received from Preferred providers when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area. However, we will not waive any of our copayments or coinsurance for services you receive from Preferred providers who do not participate in the Medicare Advantage plan. Please remember that you must receive care from Preferred providers in order to receive benefits. See page 18 for the exceptions to this requirement.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.

This health plan does not coordinate its prescription drug benefits with Medicare Part B.

A physician may have opted-out of Medicare and may or may not ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. This is different than a Non-participating doctor, and we recommend you ask your physician if they have opted-out of Medicare. Should you visit an opt-out physician, the physician will not be limited to 115% of the Medicare-approved amount. You may be responsible for paying the difference between the billed amount and our regular in-network/out-of-network benefits.

We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), regardless of whether Medicare pays.

Note: We pay our regular benefits for emergency services to a facility provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when the MRA statement is submitted to determine our payment for covered services provided to you if Medicare is primary, when Medicare does not pay the VA facility.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.

You must see Preferred providers in order to receive benefits. See page 18 for the exceptions to this requirement.

• If your physician accepts Medicare assignment, you pay nothing for covered charges.
• If your physician does not accept Medicare assignment, you pay the difference between the “limiting charge” or the physician’s charge (whichever is less) and our payment combined with Medicare’s payment.

It is important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the “limiting charge.” The Medicare Summary Notice (MSN) form that you receive from Medicare will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to the Medicare carrier that sent you the MSN form. Call us if you need further assistance.

An injury caused by an external force or element such as a blow or fall that requires immediate medical attention, including animal bites and poisonings. Note: Injuries to the teeth while eating are not considered accidental injuries. Dental care for accidental injury is limited to dental treatment necessary to repair sound natural teeth.

The period from entry (admission) as an inpatient into a hospital (or other covered facility) until discharge. In counting days of inpatient care, the date of entry and the date of discharge count as the same day.

Receiving information on the types of life-sustaining treatments that are available, completing advance directives and other standard forms, and/or if you are diagnosed with a terminal illness and making decisions about the care you would want to receive if you become unable to speak for yourself.

Medications and other substances or products given by mouth, inhaled, placed on you, or injected in you to diagnose, evaluate, and/or treat your condition. Agents include medications and other substances or products necessary to perform tests such as bone scans, cardiac stress tests, CT scans, MRIs, PET scans, lung scans, and X-rays, as well as those injected into the joint.

An authorization by the enrollee or spouse for us to issue payment of benefits directly to the provider. We reserve the right to pay you, the enrollee, directly for all covered services. Benefits provided under the contract are not assignable by the member to any person without express written approval of the Carrier, and in the absence of such approval, any such assignment shall be void.

Please visit www.fepblue.org to obtain a valid authorization form.

Reproductive services, testing, and treatments involving manipulation of eggs, sperm, and embryos to achieve pregnancy. In general, assisted reproductive technology (ART) procedures are used to retrieve eggs from a woman, combine them with sperm in the laboratory, and then implant the embryos or donate them to another woman.

A complex drug or product that is manufactured in a living organism, or its components, that is used as a diagnostic, preventive or therapeutic agent.

A U.S. FDA-approved biologic drug, which is considered highly similar to an original brand-name biologic drug, with no clinically meaningful differences from the original biologic drug in terms of safety, purity and potency.

A U.S. FDA-approved biosimilar drug that may be automatically substituted for the original brand-name biologic drug.

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

The Blue Cross and Blue Shield Association, on behalf of the local Blue Cross and Blue Shield Plans.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally funded; conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration (U.S. FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

See Section 4 page 28.

A claim for continuing care or an ongoing course of treatment that is subject to prior approval. See page 26 in Section 3.

A condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birth marks; ambiguous genitalia; and webbed fingers and toes. Note: Congenital anomalies do not include conditions related to the teeth or intra-oral structures supporting the teeth.

See Section 4 page 28.

Benefits under FEP Blue Focus that have no or a low copayment. CORE benefits are not subject to deductible or coinsurance. The benefits are most commonly used to receive general care and to maintain your overall health and well-being, but also include coverage for spinal manipulations, acupuncture and accidental injury.

Any surgical procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form, except for repair of accidental injury, or to restore or correct a part of the body that has been altered as a result of disease or surgery or to correct a congenital anomaly.

See Section 4 page 28.

Services we provide benefits for, as described in this brochure.

Facility-based care that does not require access to the full spectrum of services performed by licensed healthcare professionals that is available 24 hours a day in acute inpatient hospital settings to avoid imminent, serious, medical or psychiatric consequences. By “facility-based,” we mean services provided in a hospital, long term care facility, extended care facility, skilled nursing facility, residential treatment center, school, halfway house, group home, or any other facility providing skilled or unskilled treatment or services to individuals whose conditions have been stabilized. Custodial or long term care can also be provided in the patient’s home, however defined.

Custodial or long term care may include services that a person not medically skilled could perform safely and reasonably with minimal training, or that mainly assist the patient with daily living activities, such as:

1. Personal care, including help in walking, getting in and out of bed, bathing, eating (by spoon, tube, or gastrostomy), exercising, or dressing;
2. Homemaking, such as preparing meals or special diets;
3. Moving the patient;
4. Acting as companion or sitter;
5. Supervising medication that can usually be self-administered; or
6. Treatment or services that any person can perform with minimal instruction, such as recording pulse, temperature, and respiration; or administration and monitoring of feeding systems.

We do not provide benefits for custodial or long term care, regardless of who recommends the care or where it is provided. The Carrier, its medical staff, and/or an independent medical review determine which services are custodial or long term care.

Equipment and supplies that are:

1. Prescribed by your 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.

Experimental or investigational shall mean:

1. A drug, device, or biological product that cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (U.S. FDA); and approval for marketing has not been given at the time it is furnished; or
2. Reliable evidence shows that the healthcare service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
3. Reliable evidence shows that the consensus of opinion among experts regarding the healthcare service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
4. Reliable evidence shows that the healthcare service (e.g., procedure, treatment, supply, device, equipment, drug, biological product) does not improve net health outcome, is not as beneficial as any established alternatives, or does not produce improvement outside of the research setting.

Reliable evidence shall mean only evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations, such as:

1. Published reports and articles in the authoritative medical and scientific literature;
2. The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or
3. The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or biological product or medical treatment or procedure.

A generic alternative is a U.S. FDA-approved generic drug in the same class or group of drugs as your brand-name drug. The therapeutic effect and safety profile of a generic alternative are similar to your brand-name drug, but it has a different active ingredient.

A generic equivalent is a drug whose active ingredients are identical in chemical composition to those of its brand-name counterpart. Inactive ingredients may not be the same. A generic drug is considered “equivalent,” if it has been approved by the U.S. FDA as interchangeable with your brand-name drug.

Healthcare coverage that you are eligible for based on your employment, or your membership in or connection with a particular organization or group, that provides payment for medical services or supplies, or that pays a specific amount of more than $200 per day for hospitalization (including extension of any of these benefits through COBRA).

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law. See page 16 for information about how we determine which healthcare professionals are covered under this Plan.

A questionnaire designed to assess your overall health and identify potential health risks. Service Benefit Plan members have access to the Blue Cross and Blue Shield HRA (called the “Blue Health Assessment”) which is supported by a computerized program that analyzes your health and lifestyle information and provides you with a personal and confidential health action plan that is protected by HIPAA privacy and security provisions. Results from the Blue Health Assessment include practical suggestions for making healthy changes and important health information you may want to discuss with your healthcare provider. For more information, visit our website, www.fepblue.org.

You are an inpatient when you are formally admitted to a hospital with a doctor’s order.

Note: Inpatient care requires precertification. For some services and procedures prior approval must also be obtained. See page 19.

A comprehensive, structured outpatient treatment program that includes extended periods of individual or group therapy sessions designed to assist members with mental health and/or substance use disorders. It is an intermediate setting between traditional outpatient therapy and partial hospitalization, typically performed in an outpatient facility or outpatient professional office setting. Program sessions may occur more than one day per week. Timeframes and frequency will vary based upon diagnosis and severity of illness.

A Blue Cross and/or Blue Shield Plan that serves a specific geographic area.

The term medical food, as defined in Section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) is “a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.” In general, to be considered a medical food, a product must, at a minimum, meet the following criteria: the product must be a food for oral or tube feeding; the product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements; and the product must be intended to be used under medical supervision.

All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine that the criteria for medical necessity are met. Medical necessity shall mean healthcare services that a physician, hospital, or other covered professional or facility provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice in the United States; and
2. Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms; and
3. Not primarily for the convenience of the patient, physician, or other healthcare provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury, or disease, or its symptoms; and
4. Not part of or associated with scholastic education or vocational training of the patient; and
5. In the case of inpatient care, able to be provided safely only in the inpatient setting.

For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations.

The fact that one of our covered physicians, hospitals, or other professional or facility providers has prescribed, recommended, or approved a service or supply does not, in itself, make it medically necessary or covered under this Plan.

Under the telehealth benefit, you have on-demand access to care for common, non-emergent conditions. Examples of common conditions include sinus problems, rashes, allergies, cold and flu symptoms, etc.

Errors in medical care that are clearly identifiable, preventable, and serious in their consequences, such as surgery performed on a wrong body part, and specific conditions that are acquired during your hospital stay, such as severe bed sores. For more information, see page 7.

Medical services covered under FEP Blue Focus NON-CORE benefits are subject to the deductible and coinsurance. These services include hospitalization, surgery, transplant coverage, etc.

Although you may stay overnight in a hospital room and receive meals and other hospital services, some services and overnight stays – including “observation services” – are actually outpatient care. Observation care includes care provided to members who require significant treatment or monitoring before a physician can decide whether to admit them on an inpatient basis, or discharge them to home. The provider may need 6 to 24 hours or more to make that decision.

If you are in the hospital more than a few hours, always ask your physician or the hospital staff if your stay is considered inpatient or outpatient.

You are an outpatient if you are getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor has not written an order to admit you to a hospital as an inpatient. In these cases, you are an outpatient even if you are admitted to a room in the hospital for observation and spend the night at the hospital.

Our Plan allowance is the amount we use to determine our payment and your cost-share for covered services. Fee-for-service plans determine their allowances in different ways. If the amount your provider bills for covered services is less than our allowance, we base your share (coinsurance, deductible, and/or copayments), on the billed amount. We determine our allowance as follows:

• PPO providers (Preferred provider) – Our allowance (which we may refer to as the “PPA” for “Preferred Provider Allowance”) is the negotiated amount that Preferred providers (hospitals and other facilities, physicians, and other covered healthcare professionals that contract with each local Blue Cross and Blue Shield Plan, and retail pharmacies that contract with CVS Caremark) have agreed to accept as payment in full, when we pay primary benefits.
  
  Our PPO allowance includes any known discounts that can be accurately calculated at the time your claim is processed. For PPO facilities, we sometimes refer to our allowance as the “Preferred rate.” The Preferred rate may be subject to a periodic adjustment after your claim is processed that may decrease or increase the amount of our payment that is due to the facility. However, your cost-sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of this Plan. If our payment amount is increased, we pay that cost on your behalf.

• Participating providers (Non-preferred provider) – Our allowance (which we may refer to as the “PAR” for “Participating Provider Allowance”), applied when a service is paid due to an exception listed on page 18, is the negotiated amount that these providers (hospitals and other facilities, physicians, and other covered healthcare professionals that contract with some local Blue Cross and Blue Shield Plans) have agreed to accept as payment in full, when we pay primary benefits. For facilities, we sometimes refer to our allowance as the “Member rate.” The Member rate includes any known discounts that can be accurately calculated at the time your claim is processed, and may be subject to a periodic adjustment after your claim is processed that may decrease or increase the amount of our payment that is due to the facility. However, your cost-sharing (if any) does not change. If our payment amount is decreased, we credit the amount of the decrease to the reserves of this Plan. If our payment amount is increased, we pay that cost on your behalf.
• Non-participating providers (Non-preferred provider) – We have no agreements with these providers to limit what they can bill you for their services. This means that using Non-participating providers for exceptions listed on page 18 could result in your having to pay significantly greater amounts for the services you receive. We determine our allowance as follows:
  • For inpatient services at hospitals, and other facilities that do not contract with your local Blue Cross and Blue Shield Plan (“Non-member facilities”), our allowance is based on the Local Plan Allowance. The Local Plan Allowance varies by region and is determined by each Plan. If you would like additional information, or to obtain the current allowed amount, please call the customer service phone number on the back of your ID card. For inpatient stays resulting from medical emergencies or accidental injuries, or for emergency deliveries, our allowance is the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations;
  • For outpatient services resulting from a medical emergency or accidental injury that are billed by Non-member facilities, our allowance is the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations (minus any amount for noncovered services);
  • For physicians and other covered healthcare professionals that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is equal to the greater of (1) the Medicare participating fee schedule amount or the Medicare Part B Drug Average Sale Price (ASP) for the service, drug, or supply in the geographic area in which it was performed or obtained or (2) 100% of the Local Plan Allowance. In the absence of a Medicare participating fee schedule amount or ASP for any service, drug, or supply, our allowance is the Local Plan Allowance. Contact your Local Plan if you need more information. We may refer to our allowance for Non-participating providers as the “NPA” (for “Non-participating Provider Allowance”);
  • For non-emergency medical services performed in Preferred hospitals provided by physicians and other covered healthcare professionals identified under the NSA (see page 29) that do not contract with your local Blue Cross and Blue Shield Plan and cannot balance bill you under this regulation, our allowance is equal to the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations;
  • For emergency medical and mental health and substance use disorders services performed in the emergency department of a hospital provided by physicians and other covered healthcare professionals, and air ambulance providers that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is equal to the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations;
  • For services you receive outside of the United States, Puerto Rico, and the U.S. Virgin Islands from providers that do not contract with us or with the Overseas Assistance Center (provided by GMMI), we use our Overseas Fee Schedule to determine our allowance. Our fee schedule is based on a percentage of the amounts we allow for Non-participating providers in the Washington, D.C., area, or a customary percent of billed charge, whichever is higher.

Note: Using Non-participating or Non-member providers (Non-preferred) when an exception is granted (see page 18) could result in your having to pay significantly greater amounts for the services you receive. Non-participating and Non-member providers are under no obligation to accept our allowance as payment in full. If you use Non-participating and/or Non-member providers, you will be responsible for any difference between our payment and the billed amount (except in certain circumstances involving covered Non-participating professional care – see below). In addition, you will be responsible for any applicable deductible, coinsurance, or copayment. You can reduce your out-of-pocket expenses by using Preferred providers whenever possible. To locate a Preferred provider, visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer service phone number on the back of your ID card. We encourage you to always use Preferred providers for your care.

Note: For certain covered services from Non-participating professional providers, your responsibility for the difference between the Non-participating Provider Allowance (NPA) and the billed amount may be limited. See page 29, Important Notice About Surprise Billing.

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

The requirement to contact the local Blue Cross and Blue Shield Plan serving the area where the services will be performed before being admitted for inpatient care. Please refer to the precertification information listed in Section 3.

An arrangement between Local Plans and physicians, hospitals, healthcare institutions, and other covered healthcare professionals (or for retail pharmacies, between pharmacies and CVS Caremark) to provide services to you at a reduced cost. The PPO provides you with an opportunity to reduce your out-of-pocket expenses for care by selecting your facilities and providers from among a specific group. PPO providers are available in most locations; using them whenever possible helps contain healthcare costs and reduces your out-of-pocket costs. The selection of PPO providers is solely the Local Plan’s (or for pharmacies, CVS Caremark’s) responsibility. We cannot guarantee that any specific provider will continue to participate in these PPO arrangements.

Those claims (1) that require precertification or prior approval, and (2) where failure to obtain precertification or prior approval results in a reduction of benefits.

Adult preventive care includes the following services: preventive office visits and exams (including health screening services: to measure height, weight, blood pressure, heart rate, and Body Mass Index (BMI)); general health panel; basic or comprehensive metabolic panel; fasting lipoprotein profile; urinalysis; CBC; screening for diabetes mellitus, hepatitis B and hepatitis C, and latent tuberculosis; screening for alcohol/substance use disorders; counseling on reducing health risks; screening for depression; screening for chlamydia, syphilis, gonorrhea, HPV, and HIV; screening for intimate partner violence for women of reproductive age; administration and interpretation of a Health Risk Assessment questionnaire; cancer screenings including low-dose CT screening for lung cancer; screening for abdominal aortic aneurysms; and osteoporosis screening, as specifically stated in this brochure; and immunizations as licensed by the U.S. Food and Drug Administration (U.S. FDA). Note: Anesthesia services and pathology services associated with preventive colorectal surgical screenings are also paid as preventive care.

Written assurance that benefits will be provided by:

1. The Local Plan where the services will be performed; or
2. The Retail Pharmacy Program or the Specialty Drug Pharmacy Program.

For more information, see the benefit descriptions in Section 5 and Other services in Section 3, under You need prior Plan approval for certain services, on pages 19-22.

A Carrier’s pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers’ compensation program or insurance policy, and the terms of the Carrier’s health benefits plan require the covered individual, as a result of such payment, to reimburse the Carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

The act of returning to the country of birth, citizenship or origin.

Services that are not related to a specific illness, injury, set of symptoms, or maternity care (other than those routine costs associated with a clinical trial as defined on page 128).

An examination or test of an individual with no signs or symptoms of the specific disease for which the examination or test is being done, to identify the potential for that disease and prevent its occurrence.

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.

Pharmaceutical products that are included on the FEP Blue Focus Specialty Drug List that are typically high in cost and have one or more of the following characteristics:

• Injectable, infused, inhaled, or oral therapeutic agents, or products of biotechnology
• Complex drug therapy for a chronic or complex condition, and/or high potential for drug adverse effects
• Specialized patient training on the administration of the drug (including supplies and devices needed for administration) and coordination of care is required prior to drug therapy initiation and/or during therapy
• Unique patient compliance and safety monitoring requirements
• Unique requirements for handling, shipping, and storage

A Carrier’s pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers’ compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from the Carrier’s health benefits plan.

Under the telehealth benefit, dermatologic conditions seen and treated include but are not limited to acne, dermatitis, eczema, psoriasis, rosacea, seborrheic keratosis, fungal infections, scabies, suspicious moles, and warts. Members capture important digital images, combine those with the comprehensive questionnaire responses, and send those to the dermatology network without requiring a phone or video interaction.

Non-emergency services provided by phone or secure online video/messaging for minor acute conditions (see page 131 for definition), dermatology care, behavioral health and substance use disorder counseling, and nutritional counseling. Go to www.fepblue.org/telehealth or call 855-636-1579, TTY: 855-636-1578, toll free to access this benefit. After your telehealth visit, please follow up with your primary care provider or specialist.

Services provided by phone or secure online video/messaging for evaluation and management services. This does not include the use of fax machine or email; costs associated with enabling or maintaining providers’ telehealth (telemedicine) technologies; or fees for asynchronous services—medical information stored and forwarded to be reviewed at a later time by a physician or healthcare practitioner at a distant site without the patient being present. Providers must perform covered services acting within the scope of their license or certification under applicable state law. Please note, your healthcare provider must know when and where they can treat you. You, in turn, are responsible for accurately identifying to your provider where you are physically located for the service you received through telehealth (telemedicine) technologies. You and your physician must be in the same U.S. State, Territory, or foreign country as required by applicable legislation.

A defined number of consecutive days associated with a covered organ/tissue transplant procedure.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will judge whether a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our customer service department using the phone number on the back of your ID card and tell us the claim is urgent. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

“Us,” “we,” and “our” refer to the Blue Cross and Blue Shield Service Benefit Plan, and the local Blue Cross and Blue Shield Plans that administer it.

FEP Blue Focus WRAP benefits are not subject to the deductible and have either a different copayment than the copayment applied under the CORE benefits (i.e., $25 for the combined 25 visits for physical therapy) or a different coinsurance level than the coinsurance applied under the NON-CORE benefits
(i.e., brand-name preferred drugs are paid at 40% of the Plan allowance up to $350 per 30-day prescription).

“You” and “your” refer to the enrollee (the contract holder eligible for enrollment and coverage under the Federal Employees Health Benefits Program and enrolled in the Plan) and each covered family member.

Preferred provider: Nothing
Non-preferred (Participating/Non-participating): You pay all charges

41-44

Preferred provider: Nothing
Non-preferred (Participating/Non-participating): You pay all charges

44-45

Preferred provider: $10 for the first 10 visits per calendar year (combined medical and mental health and substance use disorder)
After the 10th visit: 30%* of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges

39

Preferred provider: 30%* of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges

39-40

Preferred Telehealth Provider: Nothing for the first 2 visits per calendar year
After the 2nd visit: $10 copayment per visit
Non-preferred (Participating/Non-participating): You pay all charges

39, 86

Preferred: 30%* of the Plan allowance (deductible applies)

Non-preferred (Member/Non-member): You pay all charges

70-71

Preferred: 30%* of the Plan allowance (deductible applies)

Non-preferred (Member/Non-member): You pay all charges

73-76

Preferred: Nothing for outpatient hospital and physician services within 72 hours (regular benefits apply thereafter)

Non-preferred:

• Participating: Nothing for outpatient hospital and physician services within 72 hours (regular benefits thereafter)
• Non-participating: Any difference between the Plan allowance and billed amount for outpatient hospital and physician services within 72 hours; regular benefits thereafter

Ambulance transport services: Nothing

82

Professional, outpatient hospital:

Preferred urgent care: $25 copayment; PPO and Non-PPO emergency room care: 30%* of our allowance (deductible applies); Regular benefits for physician and hospital care* provided in other than the emergency room/PPO urgent care center

Maternity:

Ambulance transport services: 30%* of our allowance (deductible applies)

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

83

Preferred provider: $10 for the first 10 visits per calendar year (combined medical and mental health and substance use disorder)

After the 10th visit: 30%* of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating): You pay all charges

86

Preferred provider: 30%* of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating): You pay all charges

85-88

Preferred retail pharmacy Tier 1 (generic): $5 copayment up to a 30-day supply

Preferred retail pharmacy Tier 2 (brand name): 40% coinsurance of the Plan allowance (up to a $350 maximum) for up to a 30-day supply

Non-preferred pharmacy: You pay all charges

93

Preferred specialty pharmacy

Tier 2: 40% coinsurance of the Plan allowance (up to a $350 maximum) for up to a 30-day supply

98

Treatment of an accidental dental injury within 72 hours (regular benefits apply thereafter)

Preferred: Nothing

Non-Preferred:

• Participating: Nothing (no deductible)
• Non-participating: Any difference between our allowance and the billed amount (no deductible)

101

See Section 5(h).

103-106

• Self Only: Nothing after $8,500 per contract per year
• Self Plus One: Nothing after $17,000 (PPO) per contract per year
• Self and Family: Nothing after $17,000 per family per year

Notes:

• Some costs do not count toward this protection.
• When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.

30