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 48
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 48
Benefit Description
Reproductive Services (cont.)
Note: See Section 5(a) for covered labs, diagnostic tests, and X-rays.
You Pay
Continued from previous page:
Reproductive Services (cont.)
- We cover one year of sperm and egg storage for individuals facing iatrogenic infertility, once per lifetime. We provide the benefits seen here when billed by a facility. See page 21 for prior approval requirements. See Section 10 for our definition of iatrogenic infertility.
Note: See Section 5(a) for covered labs, diagnostic tests, and X-rays.
You Pay
Continued from previous page:
- 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
Not covered: The services listed below are not covered as treatments for infertility or as alternatives to conventional conception:
You Pay
All charges
Not covered: The services listed below are not covered as treatments for infertility or as alternatives to conventional conception:
- Assisted reproductive technology (ART) and assisted insemination procedures, including but not limited to:
- Artificial insemination (AI)
- In vitro fertilization (IVF)
- Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT)
- Intravaginal insemination (IVI)
- Intracervical insemination (ICI)
- Intracytoplasmic sperm injection (ICSI)
- Intrauterine insemination (IUI)
- Artificial insemination (AI)
- Services, procedures, and/or supplies that are related to ART and assisted insemination procedures
- Cryopreservation or storage of sperm (sperm banking), eggs, or embryos except as described above
- Preimplantation diagnosis, testing, and/or screening, including the testing or screening of eggs, sperm, or embryos
- Drugs used in conjunction with ART and assisted insemination procedures
- Drugs to treat infertility
- Services, supplies, or drugs provided to individuals not enrolled in this Plan
You Pay
All charges
Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.
Benefit Description
Allergy Care
Note: See page 39 for applicable office visit copayment.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
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:
Benefit Description
Allergy Care
- Allergy testing
- Allergy treatment
- Allergy injections
- Sublingual allergy desensitization drugs as licensed by the U.S. FDA
- Preparation of each multi-dose vial of antigen
- Agents, drugs, and/or supplies administered or obtained in connection with your care
Note: See page 39 for applicable office visit copayment.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
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: 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
Not covered: Provocative food testing
You Pay
All charges
Not covered: Provocative food testing
You Pay
All charges