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
Preventive Care, Adult
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Preventive Care, Adult
Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.
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.
The following preventive services are covered at the time interval recommended at each of the links below.
Notes:
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).
Note: Many Preferred retail pharmacies participate in our vaccine network. See page 95 for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Benefit Description
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
- Colorectal cancer tests, including:
- Colonoscopy with or without biopsy (see page 57 for our payment levels for diagnostic colonoscopies)
- DNA analysis of stool samples
- Double contrast barium enema
- Fecal occult blood test
- Sigmoidoscopy
- Colonoscopy with or without biopsy (see page 57 for our payment levels for diagnostic colonoscopies)
- Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or triglycerides)
- General health panel
- Prostate cancer tests – Prostate Specific Antigen (PSA) test
- Screening for chlamydial infection
- Screening for diabetes mellitus
- Screening for gonorrhea infection
- Screening for human immunodeficiency virus (HIV)
- Screening mammograms, including mammography using digital technology
- Ultrasound for abdominal aortic aneurysm for adults, ages 65 to 75, limited to one screening per lifetime
- Urinalysis
The following preventive services are covered at the time interval recommended at each of the links below.
- Immunizations such as COVID-19, Pneumococcal, influenza, shingles, tetanus/DTaP) and human papillomavirus (HPV). For a complete list of immunizations, go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules.
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to certain age ranges, frequencies, and/or other patient-specific indications, including gender.
- USPSTF A and B recommended screenings such as cancer, osteoporosis, depression, and high blood pressure. For a complete list of covered A and B recommendation screenings and age and frequency limitations, go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
- Well woman care such as gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services, go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
- To build your personalized list of preventive services, go to https://health.gov/myhealthfinder
Notes:
- We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year. If you receive both preventive and diagnostic services from your Provider on the same day, you are responsible for paying your cost-share for the diagnostic services. Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance and deductible.
- See page 96 for our payment levels for medications to promote better health as recommended under the Affordable Care Act.
- See page 97 for our payment levels for bowel preparation medications, and antiretroviral medications for the prevention of HIV.
- Unless otherwise noted, the benefits listed above and on pages 41-42 do not apply to children up to age 22. (See benefits under Preventive Care, Child, in this Section.)
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).
Note: Many Preferred retail pharmacies participate in our vaccine network. See page 95 for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Benefit Description
Hereditary Breast and Ovarian Cancer Screening
Benefits are available for screening members, age 18 and over (including children ages 18 – 21) limited to one of each type of test per lifetime, to evaluate the risk for developing certain types of hereditary breast or ovarian cancer related to mutations in BRCA1 and BRCA2 genes:
Notes:
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: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits for Preferred providers. Benefits are not available for BRCA testing performed at Member or Non-member facilities.
Hereditary Breast and Ovarian Cancer Screening
Benefits are available for screening members, age 18 and over (including children ages 18 – 21) limited to one of each type of test per lifetime, to evaluate the risk for developing certain types of hereditary breast or ovarian cancer related to mutations in BRCA1 and BRCA2 genes:
- Genetic counseling and evaluation for members whose personal and/or family history is associated with an increased risk for harmful mutations in BRCA1 and BRCA2 genes.
- BRCA testing for members whose personal and/or family history is associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes.
Notes:
- You must receive genetic counseling and evaluation services and obtain prior approval before you receive preventive BRCA testing. Preventive care benefits will not be provided for BRCA testing unless you receive genetic counseling and evaluation prior to the test, and scientifically valid screening measures are used for the evaluation, and the results support BRCA testing. See page 19 for information about prior approval and additional BRCA coverage or call the phone number on the back of your ID card for additional policy information.
- See page 57 for the benefits available for the surgical removal of breast, ovaries, or prostate when screening reveals a BRCA mutation: preventive care benefits are not available.
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: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits for Preferred providers. Benefits are not available for BRCA testing performed at Member or Non-member facilities.
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Genetic testing related to family history of cancer or other disease, except as described above
Note: See page 40 for our coverage of medically necessary diagnostic genetic testing.
- 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
- Self-administered health risk assessments (other than the Blue Health Assessment)
- Screening services requested solely by the member, such as commercially advertised heart scans, body scans, and tests performed in mobile traveling vans
- Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel
- Immunizations, boosters, and medications for travel or work-related exposure. Medical benefits may be available for these services.
- Phone consultations and online medical evaluation and management services (telemedicine) for preventive services, except as noted on page 41 for nutritional counseling
You Pay
All charges