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 41
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 41
Benefit Description
Lab, X-ray and Other Diagnostic Tests (cont.)
Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.
You Pay
Continued from previous page:
Note: When care is provided by a Non-preferred laboratory and/or radiologist, as stated on page 18 for an exception, you pay:
Lab, X-ray and Other Diagnostic Tests (cont.)
- Notes:
- Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient’s existing medical condition. Benefits are not provided for genetic panels when some or all of the tests included in the panel are not covered, are experimental or investigational, or are not medically necessary. Refer to the next paragraph for information about diagnostic BRCA.
- You must obtain prior approval for BRCA testing (see page 43). Diagnostic BRCA testing, including testing for large genomic rearrangements in the BRCA1 and BRCA2 genes: Benefits are available for members with a cancer diagnosis when the requirements in the note above are met, and the member does not meet criteria for Preventive BRCA testing. Benefits are limited to one test of each type per lifetime whether covered as a diagnostic test or paid under Preventive Care benefits (see page 43).
- See page 43 in this Section for coverage of genetic counseling and testing services related to family history of cancer or other disease.
- Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient’s existing medical condition. Benefits are not provided for genetic panels when some or all of the tests included in the panel are not covered, are experimental or investigational, or are not medically necessary. Refer to the next paragraph for information about diagnostic BRCA.
- Nuclear medicine
- Sleep studies
Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.
You Pay
Continued from previous page:
Note: When care is provided by a Non-preferred laboratory and/or radiologist, as stated on page 18 for an exception, you pay:
- Participating laboratories or radiologists: 30% of the Plan allowance (deductible applies)
- Non-participating laboratories or radiologists: 30% of the Plan allowance, plus any difference between our allowance and the billed amount (deductible applies)
Benefit Description
Preventive Care, Adult
Benefits are provided for preventive care services for adults age 22 and over.
Covered services include:
Preventive care benefits for each of the services listed below are limited to one per calendar year.
You Pay
Preferred: Nothing (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Note: When care is provided by a Non-preferred laboratory and/or radiologist, as stated on page 18 for an exception, you pay:
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Note: For services billed by Non-preferred providers (Participating/Non-participating) related to influenza (flu) vaccines, we pay the Plan allowance. If you receive the influenza (flu) vaccine from a Non-participating provider, you pay any difference between our allowance and the billed amount (no deductible).
Preventive Care, Adult
Benefits are provided for preventive care services for adults age 22 and over.
Covered services include:
- Counseling on prevention and reducing health risks
- Nutritional counseling
Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
- Visits/exams for preventive care
Note: See the definition of Preventive Care, Adult, on page 134 for included health screening services.
Preventive care benefits for each of the services listed below are limited to one per calendar year.
- Administration and interpretation of a Health Risk Assessment (HRA) questionnaire (see Definitions)
Note: As a member of FEP Blue Focus, you have access to the Blue
Cross and Blue Shield HRA, called the “Blue Health Assessment” questionnaire. See Section 5(h) for more information.
- Basic or comprehensive metabolic panel test
- CBC
- Cervical cancer screening tests
- Human papillomavirus (HPV) tests of the cervix
- Pap tests of the cervix
- Human papillomavirus (HPV) tests of the cervix
You Pay
Preferred: Nothing (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Note: When care is provided by a Non-preferred laboratory and/or radiologist, as stated on page 18 for an exception, you pay:
- Participating laboratories or radiologists: Nothing (no deductible)
- Non-participating laboratories or radiologists: The difference between our allowance and the billed amount (no deductible)
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Note: For services billed by Non-preferred providers (Participating/Non-participating) related to influenza (flu) vaccines, we pay the Plan allowance. If you receive the influenza (flu) vaccine from a Non-participating provider, you pay any difference between our allowance and the billed amount (no deductible).
Preventive Care, Adult - continued on next page