2024 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 72
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 72
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:
- Prescribed drugs and medications
Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage, or you are enrolled in the FEP Medicare Prescription Drug Program. See Section 5(f) for information about specialty drug fills from a Preferred pharmacy.
- Orthopedic and prosthetic devices
- Durable medical equipment
- Surgical implants
- 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 facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Benefit Description
Residential Treatment Center
Inpatient Residential Treatment Center:
Precertification prior to admission is required.
We cover inpatient care provided and billed by an RTC when the care is medically necessary for the treatment of a medical, mental health, and/or substance use disorder:
Notes:
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Residential Treatment Center
Inpatient Residential Treatment Center:
Precertification prior to admission is required.
We cover inpatient care provided and billed by an RTC when the care is medically necessary for the treatment of a medical, mental health, and/or substance use disorder:
- Room and board, such as semiprivate room, nursing care, meals, special diets, ancillary charges, and covered therapy services when billed by the facility.
Notes:
- For inpatient care received overseas, refer to Section 5(i).
- For outpatient residential treatment center services, see Section 5(c).
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Benefit Description
Not covered services, such as:
You Pay
All charges
Not covered services, such as:
- Biofeedback
- Custodial or long-term care (see Definitions)
- Domiciliary care provided because care in the home is not available or is unsuitable
- Educational therapy or educational classes
- Equine/hippotherapy provided during the approved stay
- Recreational therapy
- Respite care
- Outdoor residential programs
- Outward Bound programs
- Personal comfort items, such as guest meals and beds, phone, television, beauty and barber service
- Services provided outside of the provider’s licensure/scope of practice
You Pay
All charges
Residential Treatment Center - continued on next page