2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5. FEP Blue Focus Overview
Page 37
Section 5. FEP Blue Focus Overview
Page 37
WRAP
Benefits with different copayments or coinsurance and no deductible - limits may apply
Brochure Section: 5(a)
Benefit: Maternity – professional
Member Payment & Calendar Year Limitations: $0
Page(s): 45
Brochure Section: 5(c)
Benefit: Maternity – facility
Member Payment & Calendar Year Limitations: $1,500 per pregnancy
Page(s): 71-72
Brochure Section: 5(a)
Benefit: Occupational, physical or speech therapy
Member Payment & Calendar Year Limitations: $25/visit Limited to 25 visits combined
Page(s): 50
Brochure Section: 5(c)
Benefit: Hospice – Traditional (home)
Member Payment & Calendar Year Limitations: $0
Page(s): 79
Brochure Section: 5(f)
Benefit: Preferred retail pharmacy – Tier 2 (Preferred Brand-name drugs)
Member Payment & Calendar Year Limitations: 40% of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
40% of the Plan allowance (up to a $1,050 maximum) for up to a 90-day supply
Page(s): 93
Brochure Section: 5(f)
Benefit: Specialty pharmacy – Tier 2 (Preferred Generic Specialty drugs and Preferred Brand-name Specialty Drugs)
Member Payment & Calendar Year Limitations: 40% of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
Page(s): 93
Benefits with different copayments or coinsurance and no deductible - limits may apply
Brochure Section: 5(a)
Benefit: Maternity – professional
Member Payment & Calendar Year Limitations: $0
Page(s): 45
Brochure Section: 5(c)
Benefit: Maternity – facility
Member Payment & Calendar Year Limitations: $1,500 per pregnancy
Page(s): 71-72
Brochure Section: 5(a)
Benefit: Occupational, physical or speech therapy
Member Payment & Calendar Year Limitations: $25/visit Limited to 25 visits combined
Page(s): 50
Brochure Section: 5(c)
Benefit: Hospice – Traditional (home)
Member Payment & Calendar Year Limitations: $0
Page(s): 79
Brochure Section: 5(f)
Benefit: Preferred retail pharmacy – Tier 2 (Preferred Brand-name drugs)
Member Payment & Calendar Year Limitations: 40% of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
40% of the Plan allowance (up to a $1,050 maximum) for up to a 90-day supply
Page(s): 93
Brochure Section: 5(f)
Benefit: Specialty pharmacy – Tier 2 (Preferred Generic Specialty drugs and Preferred Brand-name Specialty Drugs)
Member Payment & Calendar Year Limitations: 40% of the Plan allowance (up to a $350 maximum) for up to a 30-day supply
Page(s): 93
NOT COVERED
See “Not covered” at the end of each sub-section and Section 6, General Exclusions, page 111 for complete information regarding services, drugs or supplies not covered under FEP Blue Focus.
Benefit: Hearing aids including bone-anchored hearing aids
Member Payment: All charges
Benefit: Wigs
Member Payment: All charges
Benefit: Skilled nursing facility
Member Payment: All charges
Benefit: Non-preferred generic, non-preferred brand-name and non-preferred specialty generic and brand-name drugs (drugs not on the FEP Blue Focus formulary)
Member Payment: All charges
Benefit: Dental care (except accidental injury)
Member Payment: All charges
See “Not covered” at the end of each sub-section and Section 6, General Exclusions, page 111 for complete information regarding services, drugs or supplies not covered under FEP Blue Focus.
Benefit: Hearing aids including bone-anchored hearing aids
Member Payment: All charges
Benefit: Wigs
Member Payment: All charges
Benefit: Skilled nursing facility
Member Payment: All charges
Benefit: Non-preferred generic, non-preferred brand-name and non-preferred specialty generic and brand-name drugs (drugs not on the FEP Blue Focus formulary)
Member Payment: All charges
Benefit: Dental care (except accidental injury)
Member Payment: All charges