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

Diagnostic and Treatment Services
Outpatient professional services of physicians and other healthcare professionals:

 
  • Consultations
     
  • Second surgical opinions
     
  • Clinic visits
     
  • Office visits
     
  • Home visits
     
  • Initial examination of a newborn needing definitive treatment when covered under a Self Plus One or Self and Family enrollment
     
  • Pharmacotherapy (medication management) (See Section 5(f) for prescription drug coverage)
Note: Please refer to pages 40-41 for our coverage of laboratory, X-ray, and other diagnostic tests billed for by a healthcare professional, and to page 77 for our coverage of these services when billed for by a facility, such as the outpatient department of a hospital.

You Pay
Preferred provider: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits in Section 5(e) page 88)

Preferred provider, visits after the 10th visit: 30% of the Plan allowance

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

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 131 for more information about “agents.”)
 
Benefit Description
Telehealth professional services for:

 
  • Minor acute conditions (see page 134 for definition)
     
  • Dermatology care (see 138 for definition)
Note: Refer to Section 5(h), Wellness and Other Special Features, for information on telehealth services and how to access a provider.

You Pay
Preferred Telehealth Provider: Nothing (no deductible) for the first 2 visits per calendar year for any covered telehealth service (benefits are combined with telehealth services listed in Section 5(e) page 88)

$10 copayment per visit (no deductible) after the 2nd visit

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

 
  • During a covered hospital stay
     
  • Services for nonsurgical procedures when ordered, provided, and billed by a physician during a covered inpatient hospital admission
     
  • Medical care by the attending physician (the physician who is primarily responsible for your care when you are hospitalized) on days we pay hospital benefits

    Note: A consulting physician employed by the hospital is not the attending physician.

     
  • Consultations when requested by the attending physician
     
  • Concurrent care – hospital inpatient care by a physician other than the attending physician for a condition not related to your primary diagnosis, or because the medical complexity of your condition requires this additional medical care
     
  • Physical therapy by a physician other than the attending physician
     
  • Initial examination of a newborn needing definitive treatment when covered under a Self Plus One or Self and Family enrollment
     
  • Pharmacotherapy (medication management) (See Section 5(c) for our coverage of drugs you receive while in the hospital.)
     
  • Second surgical opinion
     
  • Nutritional counseling when billed by a covered provider

You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges
 
Benefit Description
Not covered:

 
  • Routine services except for those Preventive care services described on pages 41-47
     
  • Telephone consultations and online medical evaluation and management services except as shown in Section 5(a) page 39 and Section 5(e) page 88
     
  • Private duty nursing
     
  • Standby physicians
     
  • Routine radiological and staff consultations required by facility rules and regulations
     
  • Inpatient physician care when your admission or portion of an admission is not covered (See Section 5(c).)
     
Note: If we determine that an inpatient admission is not covered, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting.

You Pay
All charges
 

List Item:

diagnostic
treatment
services
medical
consultations
surgical
clinics
office
home
visits
examination
newborn
pharmacotherapy
lab
x-ray
billed
telehealth
acute
dermatology
inpatient
professional
nonsurgical
concurrent
care
nutritional
counseling
routine
preventative
telephone
onlyine
nursing
physicians
radiological
admission
physician