Document Number: SB24-094
Chapter: Blue Cross and Blue Shield Service Benefit Plan
Blue Cross Blue Shield Federal Employee Program
Confidential - Internal FEP and Local Plan use only.
Revision #: v1.0
Page 1 of 3
Date Published: 1/1/2024
94
2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(e). Mental Health and Substance Use Disorder Benefits
Page 94
Note: For Standard Option, we state whether or not the calendar year deductible applies for each
benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefit Description
Professional Services
We cover professional services by licensed professional mental health and substance use disorder
practitioners when acting within the scope of their license.
Standard Option - You Pay
Your cost-sharing responsibilities are no greater than for other illnesses or conditions.
Basic Option - You Pay
Your cost-sharing responsibilities are no greater than for other illnesses or conditions.
Benefit Description
Services provided by licensed professional mental health and substance use disorder practitioners
when acting within the scope of their license
• Individual psychotherapy
• Group psychotherapy
• Pharmacologic (medication) management
• Psychological testing
• Office visits
Document Number: SB24-094
Chapter: Blue Cross and Blue Shield Service Benefit Plan
Blue Cross Blue Shield Federal Employee Program
Confidential - Internal FEP and Local Plan use only.
Revision #: v1.0
Page 2 of 3
Date Published: 1/1/2024
• Clinic visits
• Home visits
• Phone consultations and online medical evaluation and management services (telemedicine)
Note: To locate a Preferred provider, visit www.fepblue.org/provider to use our National Doctor &
Hospital Finder, or contact your Local Plan at the mental health and substance use disorder phone
number on the back of your ID card.
Note: See Sections 5(a( and 5(f) for our coverage of smoking and tobacco cessation treatment.
Note: See Section 5(a) for our coverage of mental health visits to treat postpartum depression and
depression during pregnancy.
Note: We cover outpatient mental health and substance use disorder services or supplies provided and
billed by residential treatment centers at the levels shown here.
Standard Option - You Pay
Preferred: $30 copayment for the visit (no deductible)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus the difference between our
allowance and the billed amount
Basic Option - You Pay
Preferred: $35 copayment per visit
Participating/Non-participating: You pay all charges
Benefit Description
Telehealth professional services for:
• Behavioral health counseling
• Substance use disorder counseling
Document Number: SB24-094
Chapter: Blue Cross and Blue Shield Service Benefit Plan
Blue Cross Blue Shield Federal Employee Program
Confidential - Internal FEP and Local Plan use only.
Revision #: v1.0
Page 3 of 3
Date Published: 1/1/2024
Note: Refer to Section 5(h), Wellness and Other Special Features, for information on telehealth services
and how to access our telehealth provider network.
Note: Benefits are combined with telehealth services listed in Section 5(a).
Note: Copayments are waived for members with Medicare Part B primary.
Standard Option - You Pay
Preferred Telehealth provider: Nothing (no deductible) for the first 2 visits per calendar year for any
covered telehealth service
$10 copayment per visit (no deductible) after the 2
nd
visit
Participating/Non-participating: You pay all charges
Basic Option - You Pay
Preferred Telehealth provider: Nothing for the first 2 visits per calendar year for any covered telehealth
service
$15 copayment per visit after the 2
nd
visit
Participating/Non-participating: You pay all charges
Professional Services - continued on next page
Go to page 93. Go to page 95.
