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
Treatment Therapies
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Treatment Therapies
Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.
Benefit Description
Treatment Therapies
Outpatient treatment therapies:
Notes:
*Prior approval required
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Treatment Therapies
Outpatient treatment therapies:
- Chemotherapy and radiation therapy
Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also, Other services under You need prior Plan approval for certain services in Section 3 (pages 19-22).
- Intensity-modulated radiation therapy (IMRT)*, proton beam therapy*, stereotactic radiosurgery* and stereotactic body radiation therapy
Note: You must get prior approval for IMRT related to cancers, except head, neck, breast, prostate, or anal cancer. Please refer to page 20 for more information.
- Renal dialysis – Hemodialysis and peritoneal dialysis
- Intravenous (IV)/infusion therapy – Home IV or infusion therapy
Note: Home nursing visits (skilled) associated with Home IV/infusion therapy are covered as shown under Home Health Services on page 54.
- Outpatient cardiac rehabilitation
- Pulmonary rehabilitation therapy
- Applied behavior analysis (ABA)* for the treatment of an autism spectrum disorder limited to 200 hours per person, per calendar year (see prior approval requirements on page 19)
- Auto-immune infusion medications: Remicade, Renflexis or Inflectra
- Agents, drugs, and/or supplies administered or obtained in connection with your care
Notes:
- See Section 5(c) for our payment levels for treatment therapies billed for by the outpatient department of a hospital.
- See page 55 for our coverage of osteopathic and chiropractic manipulative treatment.
*Prior approval required
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Inpatient treatment therapies:
*Prior approval required
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Inpatient treatment therapies:
- Chemotherapy and radiation therapy
Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also, Other services under You need prior Plan approval for certain services in Section 3 (pages 19-22).
- Renal dialysis – Hemodialysis and peritoneal dialysis
- Pharmacotherapy (medication management) (See Section 5(c) for our coverage of drugs administered in connection with these treatment therapies.)
- Applied behavior analysis (ABA)* for the treatment of an autism spectrum disorder (see prior approval requirements on page 19)
*Prior approval required
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges