Foreign Service Benefit Plan Form Library
Below are official plan documents you may need to properly understand or receive benefits under your plan.
| Title | Description | Download |
|---|---|---|
| OFFICIAL PLAN BROCHURE | 2024 FSBP Plan Brochure | |
| SUMMARY OF BENEFITS AND COVERAGE CHART | 2024 Summary of Benefits & Coverage Chart (SBC) | |
| OFFICIAL PLAN BROCHURE | 2024 FSBP Summary of Benefits and Ancillary Programs | |
| OFFICIAL PLAN BROCHURE | 2024 FSBP – Aetna Medicare Advantage Plan Summary of Benefits | |
| OFFICIAL PLAN BROCHURE | 2024 Evidence of Coverage | |
| OFFICIAL PLAN BROCHURE | 2024 Plan Document Notice | |
| OFFICIAL PLAN BROCHURE | 2024 Schedule of Cost Sharing | |
| OFFICIAL PLAN BROCHURE | 2024 Annual Notice of Change | |
| PRESCRIPTION DRUG LIST | 2024 5 Tier Comprehensive Plus Formulary | |
| PRESCRIPTION DRUG LIST | 2024 Prior Authorization Details | |
| PRESCRIPTION DRUG LIST | 2024 Prescription Drug Guide/Formulary | |
| PRESCRIPTION DRUG LIST | 2024 Step Therapy Detail | |
| PRESCRIPTION DRUG LIST | 2024 Formulary Changes | |
| PRESCRIPTION DRUG LIST | 2024 Non-Part D Rider | |
| PRESCRIPTION DRUG LIST | 2024 Essential Health Supplemental Benefit | |
| OFFICIAL PLAN BROCHURE | 2023 FSBP Plan Brochure | |
| SUMMARY OF BENEFITS AND COVERAGE CHART | 2023 Summary of Benefits & Coverage Chart (SBC) | |
| OFFICIAL PLAN BROCHURE | 2023 Medicare Brochure | |
| OFFICIAL PLAN BROCHURE | 2023 Medicare Evidence of Coverage | |
| OFFICIAL PLAN BROCHURE | 2023 Medicare Summary of Benefits Guide | |
| OFFICIAL PLAN BROCHURE | 2023 Medicare Schedule of Cost Sharing | |
| MEMBER GUIDE | Know Where to Go Guide | |
| MEMBER FORMS | Medical Claim Form | |
| MEMBER FORMS | Contraceptive Management Exception Form | |
| MEMBER FORMS | Urine Drug Testing Coverage Guidelines | |
| MEMBER FORMS | EFT/Direct Deposit Authorization form | |
| MEMBER FORMS | Authorization for Release of Protected Health Information (PHI) form | |
| MEMBER FORMS | Wellness Incentive Claim Form | |
| AETNA CLINICAL POLICY BULLETINS (CPBs) | These documents explain how we make coverage decisions for services covered under our official Plan brochure. The medical, pharmacy and behavioral health CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. | LINK |