2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus - 2020
Page 141
 
Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.

You can obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.fepblue.org/brochure.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

Below, an asterisk (*) means the item is subject to the $500 per person ($1,000 per Self Plus One or Self and Family enrollment) calendar year deductible. If you use a Non-PPO physician, benefits are not provided.
 
Benefits

Medical services provided by physicians, specialists and other health care professionals:
  • Preventive, adult (pages 41-46)
You pay:

Preferred provider: Nothing

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

 
  • Preventive, child (pages 46-47)
You pay:

Preferred provider: Nothing

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

 
  • Professional Visits (page 39)
You pay:

Preferred provider: $10 for the first 10 visits per calendar year (combined medical and mental health and substance use disorder)

After the 10th visit: 30%* of the Plan allowance (deductible applies)

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

 
  • Diagnostic and treatment services provided in the office (pages 39-40)
You pay:

Preferred provider: 30%* of the Plan allowance (deductible applies)

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

 
  • Telehealth services (pages 39, 88)
You pay:

Preferred Telehealth Provider: Nothing for the first 2 visits per calendar year

After the 2nd visit: $10 copayment per visit

Non-preferred (Participating/Non-participating): You pay all charges
 
Services provided by a hospital:
  • Inpatient (pages 73-74)
You pay:

Preferred: 30%* of the Plan allowance (deductible applies)

Non-preferred (Member/Non-member): You pay all charges

 
  • Outpatient (pages 76-79)
You pay:

Preferred: 30%* of the Plan allowance (deductible applies)

Non-preferred (Member/Non-member): You pay all charges