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 42
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 42
Benefit Description
Preventive Care, Adult (cont.)
The following preventive services are covered at the time interval recommended at each of the links below.
You Pay
Continued from previous page:
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:
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Note: 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).
Note: Many Preferred retail pharmacies participate in our vaccine network. See page 95 for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Preventive Care, Adult (cont.)
- Colorectal cancer tests, including:
- Colonoscopy with or without biopsy (see page 57 for our payment levels for diagnostic colonoscopies)
- CT colonography
- DNA analysis of stool samples
- Double contrast barium enema
- Fecal occult blood test
- Sigmoidoscopy
- Colonoscopy with or without biopsy (see page 57 for our payment levels for diagnostic colonoscopies)
- Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or triglycerides)
- General health panel
- Prostate cancer tests – Prostate Specific Antigen (PSA) test
- Screening for chlamydial infection
- Screening for diabetes mellitus
- Screening for gonorrhea infection
- Screening for human immunodeficiency virus (HIV)
- Screening mammograms, including mammography using digital technology
- Ultrasound for abdominal aortic aneurysm for adults, ages 65 to 75, limited to one screening per lifetime
- Urinalysis
The following preventive services are covered at the time interval recommended at each of the links below.
- Immunizations such as COVID-19, Pneumococcal, influenza, shingles, tetanus/DTaP) and human papillomavirus (HPV). For a complete list of immunizations, go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules.
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to certain age ranges, frequencies, and/or other patient-specific indications, including gender.
- USPSTF A and B recommended screenings such as cancer, osteoporosis, depression, and high blood pressure. For a complete list of covered A and B recommendation screenings and age and frequency limitations, go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
- Well woman care such as gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services, go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
- To build your personalized list of preventive services, go to https://health.gov/myhealthfinder
You Pay
Continued from previous page:
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)
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Note: 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).
Note: Many Preferred retail pharmacies participate in our vaccine network. See page 95 for our coverage of these vaccines when provided by pharmacies in the vaccine network.