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
Page 45
 
Benefit Description

Preventive Care, Adult (cont.)

Immunizations limited to the following vaccines (as licensed by the U.S. Food and Drug Administration (U.S. FDA)):

 
  • Hepatitis (types A and B) for patients with increased risk or family history
  • Herpes zoster (shingles)*
  • Human papillomavirus (HPV)*
  • Influenza (flu)*
  • Measles, mumps, rubella
  • Meningococcal*
  • Pneumococcal*
  • Tetanus, diphtheria, pertussis booster
  • Varicella

*Many Preferred retail pharmacies participate in our vaccine network. See page 97 for our coverage of these vaccines when provided by pharmacies in the vaccine network.

Notes:

 
  • U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to certain age ranges, frequencies, and/or other patient-specific indications, including gender.
     
  • If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
     
  • See page 98 for our payment levels for medications to promote better health as recommended under the Affordable Care Act.
     
  • The benefits listed above and on pages 41-44 do not apply to children up to age 22. (See benefits under Preventive Care, Child, in this Section.)
     
  • Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
     
  • A complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) is available online at: www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

    HHS: www.healthcare.gov/preventive-care-benefits

    A complete list of women’s preventive services can be found at: www.healthcare.gov/preventive-care-women/

    For additional information: healthfinder.gov/myhealthfinder/default.aspx

You Pay
Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating): You pay all charges (except as noted below)

Notes:

 
  • For services billed by Non-preferred providers (Participating/Non-participating) related to Influenza (flu) vaccines, we pay the Plan allowance. If you receive the Influenza (flu) vaccine from a Non-participating provider, you pay any difference between our allowance and the billed amount (no deductible).
     
  • When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
 
Preventive Care, Adult - continued on next page