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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 57

Benefit Description

Medical Supplies (cont.)

Oxygen

Note: When billed by a skilled nursing facility, nursing home, or extended care facility, we pay benefits as shown here for oxygen, according to the contracting status of the facility. See page 80 for outpatient services received while in a skilled nursing facility.
Blood and blood plasma, except when donated or replaced, and blood plasma expanders

Note: We cover medical supplies at Preferred benefit levels only when you use a Preferred medical supply provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred medical supply providers.

You Pay
See previous page

Benefit Description

Not covered:

Infant formulas used as a substitute for breastfeeding
Diabetic supplies, except as described in Section 5(f) or when Medicare Part B is primary
Medical foods administered orally, except as described in Section 5(f)

You Pay
All charges

Benefit Description

Home Health Services

Home nursing care (skilled) for two hours per day limited to 10 visits when:

A registered nurse (R.N.) or licensed practical nurse (L.P.N.) provides the services; and
A physician orders the care.

You Pay
Preferred: $25 copayment per visit (no deductible)

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

Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient’s family
Services primarily for bathing, feeding, exercising, moving the patient, homemaking, giving medication, or acting as a companion or sitter
Services provided by a nurse, nursing assistant, health aide, or other similarly licensed or unlicensed person that are billed by a skilled nursing facility, extended care facility, or nursing home
Private duty nursing

You Pay
All charges

Benefit Description

Alternative/Manipulative Treatment

Benefits for manipulative treatment and acupuncture are subject to a combined limit of 10 visits per person per calendar year

Acupuncture is covered when performed and billed by a healthcare provider who is licensed or certified to perform acupuncture by the state where the services are provided, and who is acting within the scope of that license or certification. See page 16 for more information.

Note: See page 71 for our coverage of acupuncture when provided as anesthesia for covered surgery.

Alternative/Manipulative Treatment - continued on next page