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 40
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 40
Benefit Description
Diagnostic and Treatment Services (cont.)
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Diagnostic and Treatment Services (cont.)
- Concurrent care – hospital inpatient care by a physician other than the attending physician for a condition not related to your primary diagnosis, or because the medical complexity of your condition requires this additional medical care
- Physical therapy by a physician other than the attending physician
- 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(c) for our coverage of drugs you receive while in the hospital.)
- Second surgical opinion
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:
- Routine services except for those Preventive care services described on pages 41-45
- Costs associated with enabling or maintaining providers’ telehealth (telemedicine) technologies, non-interactive telecommunication such as email communications, or asynchronous store-and-forward telehealth services
- Private duty nursing
- Standby physicians
- Routine radiological and staff consultations required by facility rules and regulations
- Inpatient physician care when your admission or portion of an admission is not covered (See Section 5(c).)
Note: If we determine that an inpatient admission is not covered, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting.
You Pay
All charges
Benefit Description
Lab, X-ray and Other Diagnostic Tests
Diagnostic tests, such as:
*Prior approval is required
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Note: $0 member cost-share for the first 10 laboratory tests performed in each of these different laboratory test categories (Basic metabolic panels; Cholesterol screenings; Complete blood counts, Fasting lipoprotein profiles; General health panels; Urinalysis) and 10 Venipunctures when not associated with preventive maternity or accidental injury care.
Non-preferred (Participating/Non-participating): You pay all charges
Lab, X-ray and Other Diagnostic Tests
Diagnostic tests, such as:
- Laboratory tests (such as blood tests and urinalysis)
- Pathology services
- EKGs
- Cardiovascular monitoring
- EEGs
- Neurological testing
- Ultrasounds
- X-rays (including set-up of portable X-ray equipment)
- Bone density tests
- CT scans*/MRIs*/PET scans*
- Angiographies
- Genetic testing*
*Prior approval is required
Preferred: 30% of the Plan allowance (deductible applies)
Note: $0 member cost-share for the first 10 laboratory tests performed in each of these different laboratory test categories (Basic metabolic panels; Cholesterol screenings; Complete blood counts, Fasting lipoprotein profiles; General health panels; Urinalysis) and 10 Venipunctures when not associated with preventive maternity or accidental injury care.
Non-preferred (Participating/Non-participating): You pay all charges
Lab, X-ray and Other Diagnostic Tests - continued on next page