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 49
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 49
Benefit Description
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy (cont.)
Not covered:
You Pay
All charges
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy (cont.)
Not covered:
- Massage therapy
You Pay
All charges
Benefit Description
Hearing Services
Visits related to the covered hearing services listed below
You Pay
Preferred: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits in Section 5(a))
Preferred provider, visits after the 10th visit: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care.
Hearing Services
Visits related to the covered hearing services listed below
You Pay
Preferred: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits in Section 5(a))
Preferred provider, visits after the 10th visit: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care.
Benefit Description
Hearing tests related to illness or injury
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Hearing tests related to illness or injury
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:
- Routine hearing tests
- Hearing aids, including bone-anchored hearing aids, accessories or supplies (including remote controls and warranty packages) and all associated services
- Hearing aid exams
You Pay
All charges
Benefit Description
Vision Services (Testing, Treatment, and Supplies)
Eye examinations or visits related to a specific medical condition.
You Pay
Preferred: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits described at the beginning of this section)
Preferred provider, visits after the 10th visit: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care.
Vision Services (Testing, Treatment, and Supplies)
Eye examinations or visits related to a specific medical condition.
You Pay
Preferred: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits described at the beginning of this section)
Preferred provider, visits after the 10th visit: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care.
Benefit Description
Diagnostic testing and treatment, such as:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Diagnostic testing and treatment, such as:
- Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21
- Lab, X-ray, and other diagnostic tests performed or ordered by your provider.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Vision Services (Testing, Treatment, and Supplies) - continued on next page