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 48
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 48
Benefit Description
Treatment Therapies (cont.)
Notes:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Treatment Therapies (cont.)
- Applied behavior analysis (ABA)* for the treatment of an autism spectrum disorder limited to 200 hours per person, per calendar year (see prior approval requirements in Section 3)
- Auto-immune infusion medications: Remicade, Renflexis or Inflectra
- Agents, drugs, and/or supplies administered or obtained in connection with your care
Notes:
- See Section 5(c) for our payment levels for treatment therapies billed for by the outpatient department of a hospital.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Inpatient treatment therapies:
*Prior approval required
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Inpatient treatment therapies:
- Chemotherapy and radiation therapy
Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also, Other services under You need prior Plan approval for certain services in Section 3.
- Renal dialysis – Hemodialysis and peritoneal dialysis
- Pharmacotherapy (medication management) (See Section 5(c) for our coverage of drugs administered in connection with these treatment therapies.)
- Applied behavior analysis (ABA)* for the treatment of an autism spectrum disorder
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy
Outpatient treatment therapies, subject to visit limits:
You Pay
Preferred: $25 copayment per visit (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Notes:
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy
Outpatient treatment therapies, subject to visit limits:
- Physical therapy, occupational therapy, and speech therapy:
- Benefits are limited to 25 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three; regardless of the provider or facility billing for the services
- Benefits are limited to 25 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three; regardless of the provider or facility billing for the services
- Cognitive rehabilitation therapy, limited to 25 visits per calendar year, regardless of the provider billing the service
You Pay
Preferred: $25 copayment per visit (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Notes:
- You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care.
- See Section 5(c) for our payment levels for rehabilitative therapies billed for by the outpatient department of a hospital.
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay
- Maintenance or palliative rehabilitative therapy
- Exercise programs
- Hippotherapy/Equine therapy
You Pay
All charges
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy - continued on next page