Foreign Service Benefit Plan Form Library

Below are official plan documents you may need to properly understand or receive benefits under your plan.

Member Forms & Documents
Title Description Download
OFFICIAL PLAN BROCHURE 2023 FSBP Plan Brochure PDF
SUMMARY OF BENEFITS AND COVERAGE CHART 2023 Summary of Benefits & Coverage Chart (SBC) PDF
OFFICIAL PLAN BROCHURE 2023 Medicare Evidence of Coverage PDF
OFFICIAL PLAN BROCHURE 2023 Medicare Summary of Benefits Guide PDF
OFFICIAL PLAN BROCHURE 2023 Medicare Schedule of Cost Sharing PDF
OFFICIAL PLAN BROCHURE 2022 FSBP Plan Brochure PDF
SUMMARY OF BENEFITS AND COVERAGE CHART 2022 Summary of Benefits & Coverage Chart (SBC) PDF
MEMBER GUIDE Know Where to Go Guide PDF
MEMBER FORMS Medical Claim Form PDF
MEMBER FORMS Contraceptive Management Exception Form PDF
MEMBER FORMS Urine Drug Testing Coverage Guidelines PDF
MEMBER FORMS EFT/Direct Deposit Authorization form PDF
MEMBER FORMS Authorization for Release of Protected Health Information (PHI) form PDF
MEMBER FORMS Wellness Incentive Claim Form PDF