Coverage information - 9
• No pre-existing condition limitation - 9
• Minimum essential coverage (MEC) - 9
• Minimum value standard - 9
• Where you can get information about enrolling in the FEHB Program - 9
• Types of coverage available for you and your family - 9
• Family member coverage - 10
• Children’s Equity Act - 10
• When benefits and premiums start - 11
• When you retire - 11
When you lose benefits - 11
• When FEHB coverage ends - 11
• Upon divorce - 12
• Temporary Continuation of Coverage (TCC) - 12
• Finding replacement coverage - 12
• Health Insurance Marketplace - 12

General features of our Standard and Basic Options - 13
We have a Preferred Provider Organization (PPO) - 13
How we pay professional and facility providers - 13
Your rights and responsibilities - 14
Your medical and claims records are confidential - 14

Changes to our Standard Option only - 15
Changes to our Basic Option only - 15
Changes to both our Standard and Basic Options - 16

Identification cards - 17
Where you get covered care - 17
Balance Billing Protection - 17
• Covered professional providers - 17
• Covered facility providers - 18
What you must do to get covered care - 20
• Transitional care - 20
• If you are hospitalized when your enrollment begins - 20
You need prior Plan approval for certain services - 21
• Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility admission - 21
• Other services - 22
• Surgery by Non-participating providers under Standard Option - 24
How to request precertification for an admission or get prior approval for Other services - 24
• Non-urgent care claims - 25
• Urgent care claims - 25

• Concurrent care claims - 26
• Emergency inpatient admission - 26
• Maternity care - 26
• If your facility stay needs to be extended - 26
• If your treatment needs to be extended - 27 
If you disagree with our pre-service claim decision - 27
• To reconsider a non-urgent care claim - 27
• To reconsider an urgent care claim - 27
• To file an appeal with OPM - 27

Section 4. Your Costs for Covered Services - 28

Cost-share/Cost-sharing - 28
Copayment - 28
Deductible - 28
Coinsurance - 29
If your provider routinely waives your cost - 29
Waivers - 29
Differences between our allowance and the bill - 29
Important Notice About Surprise Billing — Know Your Rights - 32
Your costs for other care - 32
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments - 32
Carryover - 33
If we overpay you - 34
When Government facilities bill us - 34
The Federal Flexible Spending Account Program – FSAFEDS - 34

Section 5. Benefits - 35

Section 5. Standard and Basic Option Overview - 37

Non-FEHB Benefits Available to Plan Members - 133

Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover - 134

Section 7. Filing a Claim for Covered Services - 136
Section 8. The Disputed Claims Process - 139
Section 9. Coordinating Benefits With Medicare and Other Coverage -  142

When you have other health coverage - 142
• TRICARE and CHAMPVA - 142
• Workers’ Compensation - 143
• Medicaid - 143
When other Government agencies are responsible for your care - 143
When others are responsible for injuries - 143
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) - 144
Clinical trials - 144
When you have Medicare - 145
• The Original Medicare Plan (Part A or Part B) - 145
• Tell us about your Medicare coverage - 146
• Private contract with your physician - 146 
• Medicare Advantage (Part C) - 147
• Medicare prescription drug coverage (Part D) - 147
• Medicare prescription drug coverage (Part B) - 147
When you are age 65 or over and do not have Medicare - 149
Physicians Who Opt-Out of Medicare - 150
When you have the Original Medicare Plan (Part A, Part B, or both) - 150

Section 10. Definitions of Terms We Use in This Brochure - 152
Index - 160