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 47
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 47
Benefit Description
You Pay
All charge
- Services, procedures, and/or supplies that are related to ART and assisted insemination procedures except as described above
- Cryopreservation or storage of sperm (sperm banking), eggs, or embryos except as described above
- Preimplantation diagnosis, testing, and/or screening, including the testing or screening of eggs, sperm, or embryos
- Drugs used in conjunction with ART and assisted insemination procedures except as described above and in Section 5(f) Prescription Drug Benefits
- Services, supplies, or drugs provided to individuals not enrolled in this Plan including surrogates
You Pay
All charge
Benefit Description
Allergy Care
Note: See earlier in this section for applicable office visit copayment.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: When care is provided by a Non-preferred laboratory and/or radiologist, as stated in Section 3 for an exception, you pay:
Allergy Care
- Allergy testing
- Allergy treatment
- Allergy injections
- Sublingual allergy desensitization drugs as licensed by the U.S. FDA
- Preparation of each multi-dose vial of antigen
- Agents, drugs, and/or supplies administered or obtained in connection with your care
Note: See earlier in this section for applicable office visit copayment.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: When care is provided by a Non-preferred laboratory and/or radiologist, as stated in Section 3 for an exception, you pay:
- Participating laboratories or radiologists: 30% of the Plan allowance (deductible applies)
- Non-participating laboratories or radiologists: 30% of the Plan allowance, plus any difference between our allowance and the billed amount (deductible applies)
Benefit Description
Not covered: Provocative food testing
You Pay
All charges
Not covered: Provocative food testing
You Pay
All charges
Benefit Description
Treatment Therapies
Outpatient treatment therapies:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Treatment Therapies
Outpatient 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.
- Proton beam therapy*, stereotactic radiosurgery* and stereotactic body radiation therapy*
- Renal dialysis – Hemodialysis and peritoneal dialysis
- Intravenous (IV)/infusion therapy – Home IV or infusion therapy
Note: Home nursing visits (skilled) associated with Home IV/infusion therapy are covered as shown under Home Health Services later in this section.
- Outpatient cardiac rehabilitation
- Pulmonary rehabilitation therapy
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Treatment Therapies - continued on next page