Diagnostic and Treatment Services

This brochure version is for internal use only.

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
Diagnostic and Treatment Services

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Benefit Description

Diagnostic and Treatment Services
Outpatient professional services of physicians and other healthcare professionals:

Consultations
Genetic counseling
Second surgical opinions
Clinic visits
Office visits
Home visits
Initial examination of a newborn needing definitive treatment when covered under a Self Plus One or Self and Family enrollment
Pharmacotherapy (medication management) (See Section 5(f) for prescription drug coverage)
Phone consultations and online medical evaluation and management services (telemedicine)

Note: Please refer to pages 40-41 for our coverage of laboratory, X-ray, and other diagnostic tests billed for by a healthcare professional, and to page 74 for our coverage of these services when billed for by a facility, such as the outpatient department of a hospital.

You Pay
Preferred provider: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits in Section 5(e) page 86)

Preferred provider, visits after the 10^th 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
Telehealth professional services for:

Minor acute conditions (see page 131 for definition)
Dermatology care (see page 135 for definition)

Notes:

Refer to Section 5(h), Wellness and Other Special Features, for information on telehealth services and how to access a provider.
Copayments are waived for members with Medicare Part B primary.

You Pay
Preferred Telehealth Provider: Nothing (no deductible) for the first 2 visits per calendar year for any covered telehealth service (benefits are combined with telehealth services listed in Section 5(e) page 86)

$10 copayment per visit (no deductible) after the 2^nd visit

Non-preferred (Participating/Non-participating): You pay all charges

Benefit Description
Inpatient professional services:

During a covered hospital stay
Services for nonsurgical procedures when ordered, provided, and billed by a physician during a covered inpatient hospital admission
Medical care by the attending physician (the physician who is primarily responsible for your care when you are hospitalized) on days we pay hospital benefits
Note: A consulting physician employed by the hospital is not the attending physician.
Consultations when requested by the attending physician
Nutritional counseling when billed by a covered provider

Concurrent care – hospital inpatient care by a physician other than the attending physician for a condition not related to your primary diagnosis, or because the medical complexity of your condition requires this additional medical care
Physical therapy by a physician other than the attending physician
Initial examination of a newborn needing definitive treatment when covered under a Self Plus One or Self and Family enrollment
Pharmacotherapy (medication management) (See Section 5(c) for our coverage of drugs you receive while in the hospital.)
Second surgical opinion

You Pay
Preferred: 30% of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating): You pay all charges

Benefit Description
Not covered:

Routine services except for those Preventive care services described on pages 41-45
Costs associated with enabling or maintaining providers’ telehealth (telemedicine) technologies, non-interactive telecommunication such as email communications, or asynchronous store-and-forward telehealth services
Private duty nursing
Standby physicians
Routine radiological and staff consultations required by facility rules and regulations
Inpatient physician care when your admission or portion of an admission is not covered (See Section 5(c).)
Note: If we determine that an inpatient admission is not covered, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting.

You Pay
All charges