2023 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 75
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 75
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient treatment and therapy services performed and billed by a facility, limited to:
Note: The limitations listed above are a combined total regardless of the type of covered provider or facility billing for the services.
You Pay
Preferred facilities: $25 copayment per visit (no deductible)
Non-preferred facilities (Member/Non-member): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for supplies or drugs administered or obtained in connection with your care. (See page 128 for more information about “agents.”)
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient treatment and therapy services performed and billed by a facility, limited to:
- Cognitive rehabilitation therapy limited to 25 visits per person per calendar year
- Physical therapy, occupational therapy, and speech therapy limited to 25 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
- Manipulative treatment and acupuncture services, limited to a combined 10 visits per person.
Notes:
Note: The limitations listed above are a combined total regardless of the type of covered provider or facility billing for the services.
You Pay
Preferred facilities: $25 copayment per visit (no deductible)
Non-preferred facilities (Member/Non-member): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for supplies or drugs administered or obtained in connection with your care. (See page 128 for more information about “agents.”)
Benefit Description
Outpatient treatment services performed and billed by a facility, are limited to:
*Prior approval is required, see pages 19-22 for prior approval requirements.
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Outpatient treatment services performed and billed by a facility, are limited to:
- Outpatient applied behavior analysis* (ABA) for an autism spectrum disorder performed and billed by a facility limited to 200 hours per person, per calendar year.
Note: The limitations listed is a combined total regardless of the type of covered provider or facility billing for the services.
*Prior approval is required, see pages 19-22 for prior approval requirements.
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Benefit Description
Outpatient adult preventive care performed and billed by a facility, limited to:
Notes:
You Pay
Preferred facilities: Nothing (no deductible)
Non-preferred facilities (Member/Non-Member): Nothing (no deductible) for cancer screenings and ultrasound screening for abdominal aortic aneurysm
Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Non-preferred (Member/Non-member) facilities.
Outpatient adult preventive care performed and billed by a facility, limited to:
- Visits/exams for preventive care, screening procedures, and routine immunizations described on pages 41-43
- Cancer screenings listed on pages 41-42 and ultrasound screening for abdominal aortic aneurysm
Notes:
- See page 43 for our coverage requirements for preventive BRCA testing.
- See page 44 for our payment levels for covered preventive care services for children billed for by facilities and performed on an outpatient basis.
You Pay
Preferred facilities: Nothing (no deductible)
Non-preferred facilities (Member/Non-Member): Nothing (no deductible) for cancer screenings and ultrasound screening for abdominal aortic aneurysm
Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Non-preferred (Member/Non-member) facilities.
Outpatient Hospital or Ambulatory Surgical Center – continued on next page