This index was last updated on: 12/16/2025

 
Document Name Document Number
Cover page FSB26.00.1.1
Inside cover FSB26.00.1.2
Table of Contents FSB26.00.1.3
Introduction FSB26.00.2.1
Plain Language FSB26.00.2.2
Stop Healthcare Fraud! FSB26.00.2.3
Discrimination is Against the Law FSB26.00.2.4
Preventing Medical Mistakes FSB26.00.2.5
No pre-existing condition limitation FSB26.00.3.1.1
Minimum essential coverage (MEC) FSB26.00.3.1.2
Minimum value standard FSB26.00.3.1.3
Where you can get information about enrolling in the FEHB Program FSB26.00.3.1.4
Enrollment types available for you and your family FSB26.00.3.1.5
Family member coverage FSB26.00.3.1.6
Children's Equity Act FSB26.00.3.1.7
When benefits and premiums start FSB26.00.3.1.8
When you retire FSB26.00.3.1.9
When FEHB coverage ends FSB26.00.3.2.1
Upon divorce FSB26.00.3.2.2
Temporary Continuation of Coverage (TCC) FSB26.00.3.2.3
Finding replacement coverage FSB26.00.3.2.4
Health Insurance Marketplace FSB26.00.3.2.5
Section 1. How This Plan Works FSB26.01.0
General features of our Standard and Basic Options//We have a Preferred Provider Organization (PPO) FSB26.01.1
How we pay professional and facility providers FSB26.01.2
Your rights and responsibilities FSB26.01.3
Your medical and claims records are confidential FSB26.01.4
Section 2. Changes for 2026 FSB26.02.0
Changes to our Standard Option only FSB26.02.1
Changes to our Basic Option only FSB26.02.2
Changes to both our Standard and Basic Options FSB26.02.3
Identification cards FSB26.03.1
Where you get covered care FSB26.03.2.0
Balance Billing Protection FSB26.03.2.05
Covered professional providers FSB26.03.2.1
Covered facility providers FSB26.03.2.2
What you must do to get covered care FSB26.03.3.0
Transitional care FSB26.03.3.1
If you are hospitalized when your enrollment begins FSB26.03.3.2
You need prior Plan Approval for certain services FSB26.03.4.00
Inpatient hospital, residential treatment center, or skilled nursing facility admission FSB26.03.4.01
Other services FSB26.03.4.02
Surgery by Non-participating providers under Standard Option FSB26.03.4.03
How to request precertification for an admission or get approval for Other services FSB26.03.4.04
Non-urgent care claims FSB26.03.4.05
Urgent care claims FSB26.03.4.06
Concurrent care claims FSB26.03.4.07
Emergency inpatient admission FSB26.03.4.08
Maternity care FSB26.03.4.09
If your facility stay needs to be extended FSB26.03.4.10
If your treatment needs to be extended FSB26.03.4.11
If you disagree with our pre-service claim decision FSB26.03.5.0
To reconsider a non-urgent care claim FSB26.03.5.1
To reconsider an urgent care claim FSB26.03.5.2
To file an appeal with OPM FSB26.03.5.3
Cost share/Cost-sharing FSB26.04.01
Copayment FSB26.04.02
Deductible FSB26.04.03
Coinsurance FSB26.04.04
If your provider routinely waives your cost FSB26.04.05
Waivers FSB26.04.06
Differences between our allowance and the bill FSB26.04.07
Important Notice About Surprise Billing — Know Your Rights FSB26.04.08
Your costs for other care FSB26.04.09
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments FSB26.04.10
Carryover FSB26.04.11
If we overpay you FSB26.04.12
When Government facilities bill us FSB26.04.13
The Federal Flexible Spending Account Program – FSAFEDS FSB26.04.14
Section 5. Benefits [Table of Contents] FSB26.05.01
Section 5. Standard and Basic Option Overview FSB26.05.02
Section 5(a). Overview FSB26.05a.0
Diagnostic and Treatment Services FSB26.05a.01
Lab, X-ray and Other Diagnostic Tests FSB26.05a.02
Preventive Care, Adult FSB26.05a.03
Preventive Care, Child FSB26.05a.04
Maternity Care FSB26.05a.05
Family Planning FSB26.05a.06
Reproductive Services FSB26.05a.07
Allergy Care FSB26.05a.08
Treatment Therapies FSB26.05a.09
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy FSB26.05a.10
Hearing Services (Testing, Treatment, and Supplies) FSB26.05a.11
Vision Services (Testing, Treatment, and Supplies) FSB26.05a.12
Foot Care FSB26.05a.13
Orthopedic and Prosthetic Devices FSB26.05a.14
Durable Medical Equipment (DME) FSB26.05a.15
Medical Supplies FSB26.05a.16
Home Health Services FSB26.05a.17
Manipulative Treatment FSB26.05a.18
Alternative Treatments FSB26.05a.19
Educational Classes and Programs FSB26.05a.20
Section 5(b). Overview FSB26.05b.0
Surgical Procedures FSB26.05b.1
Reconstructive Surgery FSB26.05b.2
Oral and Maxillofacial Surgery FSB26.05b.3
Organ/Tissue Transplants FSB26.05b.4
Anesthesia FSB26.05b.5
Section 5(c). Overview FSB26.05c.0
Inpatient Hospital FSB26.05c.1
Outpatient Hospital or Ambulatory Surgical Center FSB26.05c.2
Blue Distinction Specialty Care FSB26.05c.3
Residential Treatment Center FSB26.05c.4
Extended Care Benefits/Skilled Nursing Care Facility Benefits FSB26.05c.5
Hospice Care FSB26.05c.6
Ambulance FSB26.05c.7
Section 5(d). Overview FSB26.05d.0
Accidental Injury FSB26.05d.1
Medical Emergency FSB26.05d.2
Ambulance FSB26.05d.3
Section 5(e). Overview FSB26.05e.0
Professional Services FSB26.05e.1
Inpatient Hospital or Other Covered Facility FSB26.05e.2
Residential Treatment Center FSB26.05e.3
Outpatient Hospital or Other Covered Facility FSB26.05e.4
Not Covered (Inpatient or Outpatient) FSB26.05e.5
Section 5(f). Overview FSB26.05f.0
There are important features you should be aware of FSB26.05f.01
Who can write your prescriptions FSB26.05f.02
Where you can obtain them FSB26.05f.03
What is covered FSB26.05f.04
Generic equivalents FSB26.05f.05
Disclosure of information FSB26.05f.06
These are the dispensing limitations FSB26.05f.07
Patient Safety and Quality Monitoring (PSQM) FSB26.05f.08
Prior Approval FSB26.05f.09
Standard Option Generic Incentive Program FSB26.05f.10
Medical Foods FSB26.05f.11
Here is how to obtain your prescription drugs and supplies FSB26.05f.12
Preferred Retail Pharmacies FSB26.05f.13
Non-preferred Retail Pharmacies FSB26.05f.14
Mail Service Prescription Drug Program FSB26.05f.15
Specialty Drug Pharmacy Program FSB26.05f.16
Asthma Medications FSB26.05f.17
Other Preferred Diabetic Medications, Test Strips, and Supplies FSB26.05f.18
Diabetic Meter Program FSB26.05f.19
Section 5(f). MPDP Overview FSB26.05f.20
MPDP There are important features you should be aware of FSB26.05f.21
MPDP Who can write your prescriptions FSB26.05f.22
MPDP Where you can obtain them FSB26.05f.23
MPDP What is covered FSB26.05f.24
MPDP Generic equivalents FSB26.05f.25
MPDP Disclosure of information FSB26.05f.26
MPDP These are the dispensing limitations FSB26.05f.27
MPDP Important Contact Information FSB26.05f.28
MPDP Prior Approval FSB26.05f.29
MPDP Medical Foods FSB26.05f.30
MPDP Here is how to obtain your prescription drugs and supplies FSB26.05f.31
MPDP Catastrophic Maximums FSB26.05f.32
MPDP Retail Pharmacies FSB26.05f.33
MPDP Mail Service Prescription Drug Program FSB26.05f.34
MPDP Asthma Medications FSB26.05f.35
MPDP Other Preferred Diabetic Medications, Test Strips, and Supplies FSB26.05f.36
Smoking and Tobacco Cessation Medications FSB26.05f.37
Anti-hypertensive Medications FSB26.05f.38
Over-the-counter (OTC) contraceptive drugs and devices FSB26.05f.39
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network FSB26.05f.40
Metformin and metformin extended release (excluding osmotic and modified release generic drugs) FSB26.05f.41
Medications to promote better health as recommended under the ACA FSB26.05f.42
Generic medications to reduce breast cancer risk for women FSB26.05f.43
Bowel preparation medications and antiretroviral therapy medications for HIV FSB26.05f.44
Opioid Rescue Agents FSB26.05f.45
Not Covered FSB26.05f.46
Drugs From Other Sources FSB26.05f.47
Section 5(g). Overview FSB26.05g.0
Accidental Injury Benefit FSB26.05g.1
Dental Benefits FSB26.05g.2
Health Tools FSB26.05h.01
Services for the Deaf and Hearing Impaired FSB26.05h.02
Web Accessibility for the Visually Impaired FSB26.05h.03
Travel Benefit/Services Overseas FSB26.05h.04
Healthy Families FSB26.05h.05
Diabetes Management Program FSB26.05h.06
Blue Health Assessment FSB26.05h.07
Hypertension Management Program FSB26.05h.08
Pregnancy Care Incentive Program FSB26.05h.09
Annual Incentive Limitation FSB26.05h.10
Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B FSB26.05h.11
MyBlue Customer eService FSB26.05h.12
National Doctor & Hospital Finder FSB26.05h.13
Care Management Programs FSB26.05h.14
Flexible Benefits Option FSB26.05h.15
Telehealth Services FSB26.05h.16
The fepblue Mobile Application FSB26.05h.17
Weight Loss Management Program FSB26.05h.18
Section 5(i). Services, Drugs, and Supplies Provided Overseas FSB26.05i.0
Non-FEHB Benefits Available to Plan Members FSB26.05N.0
Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover FSB26.06
Section 7. Filing a Claim for Covered Services FSB26.07
Section 8. The Disputed Claims Process FSB26.08
When you have other health coverage FSB26.09.1.0
TRICARE and CHAMPVA FSB26.09.1.1
Workers' Compensation FSB26.09.1.2
Medicaid FSB26.09.1.3
When other Government agencies are responsible for your care FSB26.09.2
When others are responsible for injuries FSB26.09.3
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) FSB26.09.4
Clinical trials FSB26.09.5
When you have Medicare FSB26.09.6.1
The Original Medicare Plan (Part A or Part B) FSB26.09.6.2
Tell us about your Medicare coverage FSB26.09.6.3
Private contract with your physician FSB26.09.6.4
Medicare Advantage (Part C) FSB26.09.6.5
Medicare prescription drug coverage (Part D) FSB26.09.6.6
Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) FSB26.09.6.6.1
Medicare prescription drug coverage (Part B) FSB26.09.6.7
Primary payor chart FSB26.09.6.8
When you are age 65 or over and do not have Medicare FSB26.09.7
Physicians Who Opt-Out of Medicare FSB26.09.8
When you have the Original Medicare Plan (Part A, Part B, or both) FSB26.09.9
Cost-share when Medicare is your primary payor FSB26.09.95
Section 10. Definitions of Terms We Use in This Brochure FSB26.10
Index FSB26.11
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option - 2026 FSB26.12.1
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option - 2026 FSB26.12.2
2026 Rate Information for the Blue Cross and Blue Shield Service Benefit Plan FSB26.13
Quick Links FSB26.QL