2020 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


Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it does not apply.
 
Benefit Description

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 (pages 19-22).

     
  • Intensity-modulated radiation therapy (IMRT)*

    Note: You must get prior approval for outpatient IMRT related to cancers, except head, neck, breast, prostate, or anal cancer. Please refer to pages 19-22 for more information.

     
  • 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 on page 57.

     
  • Outpatient cardiac rehabilitation
     
  • Pulmonary rehabilitation therapy
  • 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 on page 19)
     
  • 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.
     
  • See page 57-58 for our coverage of osteopathic and chiropractic manipulative treatment.

*Prior approval required


You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges
 
Benefit Description

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 (pages 19-22).

     
  • 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 (see prior approval requirements on page 19)

*Prior approval required

You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges
 

List Item:

calendar
deductible
treatment
therapies
outpatient
chemotherapy
radiation
therapy
intensity
modulated
intensity-modulated
IMRT
cancers
head
neck
breast
prostate
anal
transplants
renal
dialysis
hemodialysis
peritoneal
intravenous
IV
infusion
cardiac
rehabilitation
pulmodary
applied
behaviour
analysis
ABA
autism
spectrum
disorder
auto-immune
osteopathic
chiropractic
pharmacotherapy
medication
management