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 41
 
Benefit Description

Lab, X-ray and Other Diagnostic Tests (cont.)

 
  • Notes:
     
    • Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient’s existing medical condition. Benefits are not provided for genetic panels when some or all of the tests included in the panel are not covered, are experimental or investigational, or are not medically necessary. Refer to the next paragraph for information about diagnostic BRCA.
       
    • You must obtain prior approval for BRCA testing (see page 43). Diagnostic BRCA testing, including testing for large genomic rearrangements in the BRCA1 and BRCA2 genes: Benefits are available for members with a cancer diagnosis when the requirements in the note above are met, and the member does not meet criteria for Preventive BRCA testing. Benefits are limited to one test of each type per lifetime whether covered as a diagnostic test or paid under Preventive Care benefits (see pages 43-44).
       
    • See pages 43-44 in this Section for coverage of genetic counseling and testing services related to family history of cancer or other disease.
       
  • Nuclear medicine
     
  • Sleep studies

Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.

You Pay
Continued from previous page:

Note: When care is provided by a Non-preferred laboratory and/or radiologist, as stated on page 18 for an exception, you pay:

 
  • Participating laboratories or radiologists: 30% of the Plan allowance
     
  • Non-participating laboratories or radiologists: 30% of the Plan allowance, plus any difference between our allowance and the billed amount
 
Benefit Description

Preventive Care, Adult
Benefits are provided for preventive care services for adults age 22 and over, including services recommended by the U.S. Preventive Services Task Force (USPSTF).

Covered services include:

 
  • Visits/exams for preventive care

    Note: See the definition of Preventive Care, Adult on page 137 for included health screening services.

     
  • Individual counseling on prevention and reducing health risks

    Note: Preventive care benefits are not available for group counseling.

Preventive care benefits for each of the services listed below are limited to one per calendar year:
 
  • Chest X-ray
  • EKG
  • Urinalysis
  • General health panel
  • Basic or comprehensive metabolic panel test
  • CBC
  • Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or triglycerides)

You Pay
Preferred: Nothing (no deductible)

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

Note: When care is provided by a Non-preferred laboratory and/or radiologist, as stated on page 18 for an exception, you pay:

 
  • Participating laboratories or radiologists: Nothing (no deductible)
     
  • Non-participating laboratories or radiologists: The difference between our allowance and the billed amount (no deductible)
 
Preventive Care, Adult - continued on next page