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 39
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 39
Preventive Care Benefits - Here are some things to keep in mind:
- Preventive care refers to medical services, counseling, and screenings related to the prevention of disease and health-related problems, rather than curing disease or treating its symptoms.
- You must use Preferred providers in order to receive preventive benefits without cost-share, see page 18 for exceptions to this requirement.
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:
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 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
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 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
Telehealth professional services for:
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 2nd visit
Non-preferred (Participating/Non-participating): You pay all charges
Telehealth professional services for:
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 2nd visit
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Inpatient professional services:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
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
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Diagnostic and Treatment Services - continued on next page