2024 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 70
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 70
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Notes:
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Outpatient Hospital or Ambulatory Surgical Center (cont.)
- Observation services
Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. Please refer to Section 5(a) for services billed by professional providers during an observation stay and earlier in this section for information about benefits for inpatient admissions.
- Pulmonary rehabilitation
- Hospital-based clinic visits
- Outpatient hospital services and supplies related to:
- Treatment of children up to age 22 with severe dental caries.
- Dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(g), Dental Benefits.
- Treatment of children up to age 22 with severe dental caries.
Notes:
- See Section 5(d) for our payment levels for care related to a medical emergency or accidental injury.
- See Section 5(a) for our coverage of family planning services.
- See later in this section for outpatient drugs, medical devices, and durable medical equipment billed for by a facility.
- See earlier in this section for maternity care provided in an outpatient facility.
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Benefit Description
Outpatient diagnostic testing performed and billed by a facility, such as:
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, see Maternity – Facility, earlier in this section.
*Prior approval is required.
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member):
Outpatient diagnostic testing performed and billed by a facility, such as:
- Angiographies
- Bone density tests
- CT scans*/MRIs*/PET scans*
- Genetic testing*
- Nuclear medicine
- Sleep studies
- Cardiovascular monitoring
- EEGs
- Ultrasounds
- Neurological testing
- X-rays (including set-up of portable X-ray equipment)
- EKGs
- Laboratory tests and pathology services
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, see Maternity – Facility, earlier in this section.
*Prior approval is required.
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member):
- Member: 30% of the Plan allowance (deductible applies)
- Non-member: 30% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Outpatient Hospital or Ambulatory Surgical Center – continued on next page