2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 50
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 50
Benefit Description
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy
Outpatient treatment therapies, subject to visit limits:
You Pay
Preferred: $25 copayment per visit (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Notes:
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy
Outpatient treatment therapies, subject to visit limits:
- Physical therapy, occupational therapy, and speech therapy:
- Benefits are limited to 25 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three; regardless of the provider or facility billing for the services
- Benefits are limited to 25 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three; regardless of the provider or facility billing for the services
- Cognitive rehabilitation therapy, limited to 25 visits per calendar year, regardless of the provider billing the service
You Pay
Preferred: $25 copayment per visit (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Notes:
- You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 128 for more information about “agents.”)
- See Section 5(c) for our payment levels for rehabilitative therapies billed for by the outpatient department of a hospital.
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay
- Maintenance or palliative rehabilitative therapy
- Exercise programs
- Hippotherapy/Equine therapy
- Massage therapy
You Pay
All charges
Benefit Description
Hearing Services
Visits related to the covered hearing services listed below
You Pay
Preferred: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits in Section 5(a) page 39)
Preferred provider, visits after the 10th visit: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 128 for more information about “agents.”)
Hearing Services
Visits related to the covered hearing services listed below
You Pay
Preferred: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits in Section 5(a) page 39)
Preferred provider, visits after the 10th visit: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 128 for more information about “agents.”)
Benefit Description
Hearing tests related to illness or injury
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Hearing tests related to illness or injury
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Routine hearing tests (except as indicated on page 44)
- Hearing aids, including bone-anchored hearing aids, accessories or supplies (including remote controls and warranty packages) and all associated services
You Pay
All charges
Hearing Services - continued on next page