Document Number:
FBF24-046
Revision #:
v1.1
Date Published:
3/19/2024
2024 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 46
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 46
Benefit Description
Family Planning (cont.)
Family planning services for men, limited to:
Notes:
You Pay
Preferred: Nothing (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Family Planning (cont.)
Family planning services for men, limited to:
- Vasectomy
Notes:
- We also provide benefits for professional services associated with tubal ligation/occlusion/blocking procedures, vasectomy, and with the fitting, insertion, or removal of the contraceptives as shown on the previous page.
- 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.
You Pay
Preferred: Nothing (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Note: We waive your cost-share for generic oral and transdermal contraceptives when you purchase them at a Preferred retail pharmacy; see Section 5(f).
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
- Oral and transdermal contraceptives
Note: We waive your cost-share for generic oral and transdermal contraceptives when you purchase them at a Preferred retail pharmacy; see Section 5(f).
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Reversal of voluntary surgical sterilization
- Contraceptive devices not described above
- Over-the-counter (OTC) contraceptives, except as described in Section 5(f)
You Pay
All charges
Benefit Description
Reproductive Services
Members who meet our definition of infertility in Section 10, are eligible for the following reproductive services:
Note: We also provide the benefits seen here when these services are billed by an outpatient facility. See Section 5(f), Prescription Drug Benefits, for your cost-shares associated with drugs for covered AI procedures.
Note: See other sections in this brochure for benefits associated with other service performed to diagnose and treat the cause of infertility.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Reproductive Services
Members who meet our definition of infertility in Section 10, are eligible for the following reproductive services:
- Artificial insemination (AI)
- Intracervical insemination (ICI)
- Intrauterine insemination (IUI)
- Intravaginal insemination (IVI)
- Intracervical insemination (ICI)
Note: We also provide the benefits seen here when these services are billed by an outpatient facility. See Section 5(f), Prescription Drug Benefits, for your cost-shares associated with drugs for covered AI procedures.
- We cover one year of sperm and egg storage, including procurement procedures, only for individuals facing iatrogenic infertility, once per lifetime. We also provide the benefits seen here when billed by a facility. See Section 3 for prior approval requirements. See Section 10 for our definition of iatrogenic infertility.
Note: See other sections in this brochure for benefits associated with other service performed to diagnose and treat the cause of infertility.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Not covered: The services listed below are not covered as treatments for infertility or as alternatives to conventional conception:
You Pay
All charges
Not covered: The services listed below are not covered as treatments for infertility or as alternatives to conventional conception:
- Assisted reproductive technology (ART), including but not limited to:
- In vitro fertilization (IVF)
- Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT)
- Intracytoplasmic sperm injection (ICSI)
- In vitro fertilization (IVF)
You Pay
All charges
Reproductive Services - continued on next page