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This brochure version is for internal use only.

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 44

Benefit Description

Preventive Care, Adult (cont.)

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

Benefit Description

Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:

Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines as provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Future Guidelines, go to https://brightfutures.aap.org
Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations, go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html

Note: U.S. FDA licensure may restrict the use of certain vaccines to specific age ranges, frequencies, and/or other patient-specific indications, including gender.
To build your personalized list of preventive services, go to https://health.gov/myhealthfinder

Note: Preventive care benefits for each of the services listed below are limited to one per calendar year:

Screening for hepatitis B for children age 13 and over
Screening for chlamydial infection
Screening for gonorrhea infection
Cervical cancer screening tests
- Human papillomavirus (HPV) tests of the cervix
- Pap tests of the cervix
  Note: See page 43 for covered BRCA testing.
Screening for human immunodeficiency virus (HIV) infection
Screening for syphilis infection
Screening for latent tuberculosis infection for children ages 18 through 21
Nutritional counseling

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)

Notes:

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).
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.

Preventive Care, Child - continued on next page

Go to page 43. Go to page 45.