Benefit Plans Brochures And Forms-Blue Cross and Blue Shield's Federal Employee Program

Brochures & Forms

Claim forms and brochures for Service Benefit Plan members.

Plan Brochures

2018 Blue Cross and Blue Shield Service Benefit Plan Brochure

2018 Blue Cross and Blue Shield Service Benefit Plan Brochure

To order a printed brochure call 1-800-411-BLUE (2583).

2018 Standard & Basic Option Service Benefit Plan Summary

2018 Standard & Basic Option Service Benefit Plan Summary

2018 Standard Option Summary of Benefits and Coverage

2018 Standard Option Summary of Benefits and Coverage

2018 Basic Option Summary of Benefits and Coverage

2018 Basic Option Summary of Benefits and Coverage

2018 Benefits at a Glance

2018 Benefits at a Glance

2018 Pharmacy Benefit Summary Book

2018 Pharmacy Benefit Summary Book

2018 Medicare at a Glance

2018 Medicare at a Glance

Glossary of Health Coverage and Medical Terms

Glossary of Health Coverage and Medical Terms

2017 Annual Member Notice

2017 Annual Member Notice

2017 Blue Cross and Blue Shield Service Benefit Plan Brochure

2017 Blue Cross and Blue Shield Service Benefit Plan Brochure

Learn How to Submit a Claim

Get detailed instructions on how to submit a claim for medical services and prescriptions.

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Medical and Dental

Health Benefits Claim Form

If you use a provider outside of the network, you will need to complete and file a claim form for reimbursement.

Overseas members should use the Overseas Medical Claim Form.

Dental Benefits Claim Form

If you take advantage of Service Benefit Plan dental benefits, you will need to complete and file a claim form for reimbursement.

Health Benefits Election Form (SF 2809 Form)

To enroll, reenroll, or to elect not to enroll in the FEHB Program, or to change, cancel or suspend your FEHB enrollment please complete and file this form.

Authorized Representative Designation Form

Use this form to select an individual or entity to act on your behalf during the disputed claims process. You can find detailed instructions on how to file an appeal in the Disputed Claims Process document.

Pharmacy

Retail Prescription Drug Claim Form

Use this form to file a claim for reimbursement for retail prescriptions.

Overseas members should use the Overseas Retail Prescription Drug Claim Form.

Mail Service Prescription Drug Form

Use this form to order a mail order prescription.

Formulary Tier Exception Member Request Form

For all formulary tier exceptions you will need to complete and file a request form. 

Specialty Formulary Tier Exception Member Request Form

For all specialty formulary tier exceptions you will need to complete and file a request form. 

Specialty Medication Order Form

Order form for specialty medications

Primary Breast Cancer Prevention Coverage Member Request Form

Complete the Member Request Form for Primary Breast Cancer Prevention Coverage.

Prior Approval Pharmacy Forms

For more information about Pharmacy Prior Approval and the required forms visit the Prior Approval page.

Managed Formulary Exception Form

The Managed Formulary Exception (MFE) process allows a Basic Option member to apply for coverage of a “Managed Not Covered” drug at a tier 3 cost share if a member has tried and failed the covered drug(s).

Standard Option Exclusion Form

The Standard Option exclusion process allows a Standard Option member to apply for coverage of an excluded drug at a tier 3 cost share if a member has tried and failed the covered drug(s).

Dispense as Written (DAW) Exception Process

The Dispense as Written exception process allows for coverage of the brand drug without paying the difference in cost between brand and generic.

New to Market FDA-Approved Medication Review Exception Process

The New to Market FDA-Approved Medication Review Exception Process allows a member to apply for coverage of an excluded drug at a tier 3 cost share if the member has met the requirements outlined.

Overseas

Overseas Medical Claim Form

Overseas members will need to complete and file this claim form for any medical services received.

Retail Prescription Drug Overseas Claim Form

Overseas members will need to complete and file this claim form for any pharmacy services received.

AXA Provider Nomination Form

Should you wish to request to recruit a facility or physician into the AXA network, please complete this nomination form.

FEP BlueVision®

FEP BlueVision Claim Form

FEP BlueVision is neither offered nor guaranteed under contract with the FEHB Program, but is available to all enrollees and family members who become members of FEP BlueVision.

Medical Policies

Medical Policies

The policies contained in the FEP Medical Policy Manual are developed to assist in administering contractual benefits and do not constitute medical advice. They are not intended to replace or substitute for the independent medical judgment of a practitioner or other health care professional in the treatment of an individual member. The Blue Cross and Blue Shield Association does not intend by the FEP Medical Policy Manual, or by any particular medical policy, to recommend, advocate, encourage or discourage any particular medical technologies. Medical decisions relative to medical technologies are to be made strictly by members/patients in consultation with their health care providers. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that the Blue Cross and Blue Shield Service Benefit Plan covers (or pays for) this service or supply for a particular member.

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