2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5. FEP Blue Focus Overview
Page 36
Section 5. FEP Blue Focus Overview
Page 36
NON-CORE
Benefits that share a common deductible and coinsurance
Brochure Section: 5(a)
Benefit: Professional visits (combined medical and mental health and substance use disorder visits, see Section 5(e))
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Beginning with visit 11 and after
Page(s): 39, 86
Brochure Section: 5(a)
Benefit: Inpatient physician
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 39-40
Brochure Section: 5(a)
Benefit: Lab, X-ray & other diagnostic services
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 40-41
Brochure Section: 5(a)
Benefit: Lab, X-ray & other diagnostic services
Member Payment & Calendar Year Limitations (Deductible Applies): Beginning with the 11th occurrence of laboratory tests performed in each of these different laboratory test categories (Basic metabolic panels; Cholesterol screenings; Complete blood counts; Fasting lipoprotein profiles; General health panels; Urinalysis) and Venipunctures when not associated with preventive, maternity or accidental injury care, 30% of Plan Allowance after CYD
Page(s): 40
Brochure Section: 5(a)
Benefit: Allergy – testing, injections, multi-dose antigens
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 48
Brochure Section: 5(a)
Benefit: Outpatient applied behavior analysis (ABA)
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Limited to 200 hours
Page(s): 49, 75
Brochure Section: 5(a)
Benefit: Inpatient and outpatient therapies
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 49
Brochure Section: 5(a)
Benefit: Durable medical equipment
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 53
Brochure Section: 5(b)
Benefit: Surgical care – including Blue Distinction® Center
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 57, 68
Brochure Section: 5(c)
Benefit: Inpatient hospital
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 70-71
Brochure Section: 5(c)
Benefit: Outpatient hospital or ambulatory surgical center
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 73-76
Brochure Section: 5(c)
Benefit: Ambulance – medical emergency
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 80
Brochure Section: 5(c) & 5(e)
Benefit: Inpatient residential treatment centers (RTCs)
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Limited to 30 days
Page(s): 76,87
Brochure Section: 5(d)
Benefit: Accidental injury – inpatient
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 82
Brochure Section: 5(d)
Benefit: Medical emergencies (Professional, Hospital emergency room)
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 83
Brochure Section: 5(e)
Benefit: Mental health visits (combined medical and mental health and substance use disorder visits, see Section 5(e))
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Beginning with visit 11 and after
Page(s): 86
Brochure Section: 5(e)
Benefit: Mental health inpatient and outpatient professional
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 86
Brochure Section: 5(e)
Benefit: Mental health inpatient, outpatient, and intensive outpatient care – facility
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 87-88
Benefits that share a common deductible and coinsurance
Brochure Section: 5(a)
Benefit: Professional visits (combined medical and mental health and substance use disorder visits, see Section 5(e))
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Beginning with visit 11 and after
Page(s): 39, 86
Brochure Section: 5(a)
Benefit: Inpatient physician
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 39-40
Brochure Section: 5(a)
Benefit: Lab, X-ray & other diagnostic services
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 40-41
Brochure Section: 5(a)
Benefit: Lab, X-ray & other diagnostic services
Member Payment & Calendar Year Limitations (Deductible Applies): Beginning with the 11th occurrence of laboratory tests performed in each of these different laboratory test categories (Basic metabolic panels; Cholesterol screenings; Complete blood counts; Fasting lipoprotein profiles; General health panels; Urinalysis) and Venipunctures when not associated with preventive, maternity or accidental injury care, 30% of Plan Allowance after CYD
Page(s): 40
Brochure Section: 5(a)
Benefit: Allergy – testing, injections, multi-dose antigens
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 48
Brochure Section: 5(a)
Benefit: Outpatient applied behavior analysis (ABA)
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Limited to 200 hours
Page(s): 49, 75
Brochure Section: 5(a)
Benefit: Inpatient and outpatient therapies
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 49
Brochure Section: 5(a)
Benefit: Durable medical equipment
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 53
Brochure Section: 5(b)
Benefit: Surgical care – including Blue Distinction® Center
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 57, 68
Brochure Section: 5(c)
Benefit: Inpatient hospital
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 70-71
Brochure Section: 5(c)
Benefit: Outpatient hospital or ambulatory surgical center
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 73-76
Brochure Section: 5(c)
Benefit: Ambulance – medical emergency
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 80
Brochure Section: 5(c) & 5(e)
Benefit: Inpatient residential treatment centers (RTCs)
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Limited to 30 days
Page(s): 76,87
Brochure Section: 5(d)
Benefit: Accidental injury – inpatient
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 82
Brochure Section: 5(d)
Benefit: Medical emergencies (Professional, Hospital emergency room)
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 83
Brochure Section: 5(e)
Benefit: Mental health visits (combined medical and mental health and substance use disorder visits, see Section 5(e))
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Beginning with visit 11 and after
Page(s): 86
Brochure Section: 5(e)
Benefit: Mental health inpatient and outpatient professional
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 86
Brochure Section: 5(e)
Benefit: Mental health inpatient, outpatient, and intensive outpatient care – facility
Member Payment & Calendar Year Limitations (Deductible Applies): 30% of the Plan Allowance
Page(s): 87-88