2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5. FEP Blue Focus Overview
Page 35
Section 5. FEP Blue Focus Overview
Page 35
CORE
Key benefits with no or low member cost-share – not subject to deductible and coinsurance
Brochure Section: 5(a)
Benefit: Professional visit (combined medical and mental health and substance use disorder visits, see Section 5(e))
Member Payment & Calendar Year Limitations: $10 per visit for first 10 visits (See “Non-Core” for visits 11+.)
Page(s): 39, 86
Brochure Section: 5(a)
Benefit: Lab, X-ray and other diagnostic services
Member Payment & Calendar Year Limitations: $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
Page(s): 40
Brochure Section: 5(a)
Benefit: Telehealth
First 2 visits – no member cost-share
Page(s): 39, 86
Brochure Section: 5(a)
Benefit: Preventive care (adult/child)
Member Payment & Calendar Year Limitations: $0
Page(s): 41, 44
Brochure Section: 5(a)
Benefit: Family planning
Member Payment & Calendar Year Limitations: $0
Page(s): 47
Brochure Section: 5(a)
Benefit: Oral & transdermal contraceptives from Preferred pharmacy
Member Payment & Calendar Year Limitations: $0
Page(s): 95
Brochure Section: 5(a)
Benefit: Immunizations (preventive)
Member Payment & Calendar Year Limitations: $0
Page(s): 42, 44
Brochure Section: 5(a)
Benefit: Smoking cessation treatment
Member Payment & Calendar Year Limitations: $0
Page(s): 55, 98
Brochure Section: 5(a)
Benefit: Acupuncture and manipulative treatments
Member Payment & Calendar Year Limitations: $25 per visit
Limited to 10 visits combined
Page(s): 55
Brochure Section: 5(c), 5(d) & 5(g)
Benefit: Accidental injury
Within 72 hours of the accidental injury
Page(s): 80, 82, 101
Brochure Section: 5(d)
Benefit: Medical emergencies – urgent care
Member Payment & Calendar Year Limitations: $25 per visit
Page(s): 83
Brochure Section: 5(f)
Benefit: Preferred retail pharmacy - Tier 1: (Preferred Generic Drugs at a Preferred retail pharmacy)
Member Payment & Calendar Year Limitations: $5 for up to a 30-day supply
$15 for up to a 90-day supply
Page(s): 93
*The Core benefits do not include Tier 2 brand-name drugs or any specialty drugs (including generic specialty drugs), see WRAP benefits listed on page 37.
Key benefits with no or low member cost-share – not subject to deductible and coinsurance
Brochure Section: 5(a)
Benefit: Professional visit (combined medical and mental health and substance use disorder visits, see Section 5(e))
Member Payment & Calendar Year Limitations: $10 per visit for first 10 visits (See “Non-Core” for visits 11+.)
Page(s): 39, 86
Brochure Section: 5(a)
Benefit: Lab, X-ray and other diagnostic services
Member Payment & Calendar Year Limitations: $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
Page(s): 40
Brochure Section: 5(a)
Benefit: Telehealth
- Minor acute conditions
- Dermatology care
- Mental health and substance use disorder counseling
First 2 visits – no member cost-share
Page(s): 39, 86
Brochure Section: 5(a)
Benefit: Preventive care (adult/child)
Member Payment & Calendar Year Limitations: $0
Page(s): 41, 44
Brochure Section: 5(a)
Benefit: Family planning
Member Payment & Calendar Year Limitations: $0
Page(s): 47
Brochure Section: 5(a)
Benefit: Oral & transdermal contraceptives from Preferred pharmacy
Member Payment & Calendar Year Limitations: $0
Page(s): 95
Brochure Section: 5(a)
Benefit: Immunizations (preventive)
Member Payment & Calendar Year Limitations: $0
Page(s): 42, 44
Brochure Section: 5(a)
Benefit: Smoking cessation treatment
Member Payment & Calendar Year Limitations: $0
Page(s): 55, 98
Brochure Section: 5(a)
Benefit: Acupuncture and manipulative treatments
Member Payment & Calendar Year Limitations: $25 per visit
Limited to 10 visits combined
Page(s): 55
Brochure Section: 5(c), 5(d) & 5(g)
Benefit: Accidental injury
- Ambulance
- Dental
- Professional
- Outpatient hospital services
- Urgent Care
Within 72 hours of the accidental injury
Page(s): 80, 82, 101
Brochure Section: 5(d)
Benefit: Medical emergencies – urgent care
Member Payment & Calendar Year Limitations: $25 per visit
Page(s): 83
Brochure Section: 5(f)
Benefit: Preferred retail pharmacy - Tier 1: (Preferred Generic Drugs at a Preferred retail pharmacy)
Member Payment & Calendar Year Limitations: $5 for up to a 30-day supply
$15 for up to a 90-day supply
Page(s): 93
*The Core benefits do not include Tier 2 brand-name drugs or any specialty drugs (including generic specialty drugs), see WRAP benefits listed on page 37.