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 45
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 45
Benefit Description
Preventive Care, Child (cont.)
Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.
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.
Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive 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.
You Pay
See previous page
Preventive Care, Child (cont.)
Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.
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.
Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive 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.
You Pay
See previous page
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- 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 above for nutritional counseling.
You Pay
All charges
Benefit Description
Maternity Care
We encourage you to notify us of your pregnancy during the first trimester, see page 24.
Maternity (obstetrical) care including related conditions resulting in childbirth or miscarriage, such as:
You Pay
Preferred: Nothing (no deductible)
Note: For Preferred facility care related to maternity, including care at Preferred birthing facilities, your responsibility for covered facility care is limited to $1,500 per pregnancy. See Section 5(c), page 71.
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:
Maternity Care
We encourage you to notify us of your pregnancy during the first trimester, see page 24.
Maternity (obstetrical) care including related conditions resulting in childbirth or miscarriage, such as:
- Prenatal care (including ultrasound, laboratory, and diagnostic tests)
- Delivery
- Postpartum care
Note: We cover up to 8 visits per year in full to treat depression associated with pregnancy (i.e., depression during pregnancy, postpartum depression, or both) when you use a Preferred provider. See Section 5(e) for our coverage and benefits for additional mental health services.
- Assistant surgeons/surgical assistance if required because of the complexity of the delivery
- Anesthesia (including acupuncture) when requested by the attending physician and performed by a certified registered nurse anesthetist (CRNA) or a physician other than the operating physician (surgeon) or the assistant
- Tocolytic therapy and related services when provided on an inpatient basis during a covered hospital admission or during a covered observation stay
You Pay
Preferred: Nothing (no deductible)
Note: For Preferred facility care related to maternity, including care at Preferred birthing facilities, your responsibility for covered facility care is limited to $1,500 per pregnancy. See Section 5(c), page 71.
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)
Maternity Care - continued on next page