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 47
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 47
Benefit Description
Maternity Care (cont.)
You Pay
All charges
Maternity Care (cont.)
- Childbirth preparation, Lamaze, and other birthing/parenting classes
- Breast pumps and milk storage bags except as stated on page 46
- Breastfeeding supplies other than those contained in the breast pump kit described on page 46 including clothing (e.g., nursing bras), baby bottles, or items for personal comfort or convenience (e.g., nursing pads)
- Tocolytic therapy and related services except as described on page 45
- Maternity care for members not enrolled in the Service Benefit Plan
You Pay
All charges
Benefit Description
Family Planning
A range of voluntary family planning services for women, limited to:
Family planning services for men, limited to:
Notes:
You Pay
Preferred: Nothing (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Family Planning
A range of voluntary family planning services for women, limited to:
- Contraceptive counseling
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Tubal ligation or tubal occlusion/tubal blocking procedures only
Family planning services for men, limited to:
- Vasectomy
Notes:
- We also provide benefits for professional services associated with tubal ligation/occlusion/blocking procedures, vasectomy, and with the fitting, insertion, or removal of the contraceptives as shown on the previous page.
- When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
You Pay
Preferred: Nothing (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Note: We waive your cost-share for generic oral and transdermal contraceptives when you purchase them at a Preferred retail pharmacy; see Section 5(f) page 95.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
- Oral and transdermal contraceptives
Note: We waive your cost-share for generic oral and transdermal contraceptives when you purchase them at a Preferred retail pharmacy; see Section 5(f) page 95.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Reversal of voluntary surgical sterilization
- Contraceptive devices not described above
- Over-the-counter (OTC) contraceptives, except as described in Section 5(f)
You Pay
All charges
Benefit Description
Reproductive Services
Diagnosis of infertility, limited to:
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:
Reproductive Services
Diagnosis of infertility, limited to:
- Diagnostic services
- Laboratory tests
- Diagnostic tests
- Agents, drugs, and/or supplies administered or obtained in connection with your care
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:
Reproductive Services - continued on next page