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 50
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 50
Benefit Description
Vision Services (Testing, Treatment, and Supplies) (cont.)
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) (cont.)
- Refraction, only when the refraction is performed to determine the prescription for the one pair of eyeglasses, replacement lenses, or contact lenses provided per incident as described below.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:
- To correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery;
- If the condition can be corrected by surgery, but surgery is not an appropriate option due to age or medical condition;
- For the nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21
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:
- Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses, except as described above
- Deluxe eyeglass frames or lens features for eyeglasses or contact lenses such as special coating, polarization, UV treatment, etc.
- Multifocal, accommodating, toric, or other premium intraocular lenses (IOLs) including Crystalens, ReStor, and ReZoom
- Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described above
- LASIK, INTACS, radial keratotomy, and other refractive surgical services
- Refractions, including those performed during an eye examination related to a specific medical condition, except as described above
You Pay
All charges
Benefit Description
Foot Care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
Notes:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Foot Care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
Notes:
- For corresponding office visits, see the beginning of Section 5(a).
- See below, Orthopedic and Prosthetic Devices, for information on podiatric shoe inserts.
- See Section 5(b) for our coverage for surgical procedures.
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 foot care, such as cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
You Pay
All charges