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.
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
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:
Preventive care benefits for each of the services listed below are limited to one per calendar year:
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:
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)
- Screening for diabetes mellitus
- Screening for hepatitis B
- Screening for hepatitis C
- Screening for alcohol/substance use disorder
Note: See pages 58 and 100 for our coverage of smoking, tobacco, and E-cigarette cessation treatment.
- Screening for chlamydial infection
- Screening for gonorrhea infection
- Screening for human immunodeficiency virus (HIV) infection
- Screening for syphilis infection
- Screening for latent tuberculosis infection
- Administration and interpretation of a Health Risk Assessment (HRA) questionnaire (see Definitions)
Note: As a member of FEP Blue Focus, you have access to the Blue Cross and Blue Shield HRA, called the “Blue Health Assessment” questionnaire. See Section 5(h) for more information.
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)
Benefit Description
Note: We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year.
Notes:
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:
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
- Colorectal cancer tests, including:
- Fecal occult blood test
- Colonoscopy, with or without biopsy (see page 60 for our payment levels for diagnostic colonoscopies)
- Sigmoidoscopy
- Double contrast barium enema
- DNA analysis of stool samples
- Prostate cancer tests – Prostate Specific Antigen (PSA) test
- Cervical cancer screening tests
- Pap tests of the cervix
- Human papillomavirus (HPV) tests of the cervix
- Screening mammograms, including mammography using digital technology
Note: We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year.
- Low-dose CT screening for lung cancer (limited to one per year, for adults ages 55 to 80, with a history of tobacco use)
- Osteoporosis screening for women age 65 and over or women ages 50 to 65 who are at increased risk
- Ultrasound for abdominal aortic aneurysm for adults, ages 65 to 75, limited to one screening per lifetime
- Nutritional counseling
Note: Benefits are limited to individual nutritional counseling services. We do not provide benefits for group counseling services.
Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
Notes:
- 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 Section 5(c) for our payment levels for covered cancer screenings and ultrasound screenings for abdominal aortic aneurysm performed on an outpatient basis.
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)
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Benefit Description
Hereditary Breast and Ovarian Cancer Screening
Benefits are available for screening members, age 18 and over, to evaluate the risk for developing certain types of hereditary breast or ovarian cancer related to mutations in BRCA1 and BRCA2 genes:
First-degree relatives are defined as: parents, siblings, and children of the member being tested. Second-degree relatives are defined as: grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings (siblings with one shared biological parent) of the member being tested. Relatives may be living or deceased.
Notes:
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:
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits for Preferred providers. Benefits are not available for BRCA testing performed at Member or Non-member facilities.
Hereditary Breast and Ovarian Cancer Screening
Benefits are available for screening members, age 18 and over, to evaluate the risk for developing certain types of hereditary breast or ovarian cancer related to mutations in BRCA1 and BRCA2 genes:
- Genetic counseling and evaluation for members whose personal and/or family history is associated with an increased risk for harmful mutations in BRCA1 and BRCA2 genes.
- BRCA testing for members whose personal and/or family history is associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes.
Note: You must receive genetic counseling and evaluation services and obtain prior approval before you receive preventive BRCA testing. Preventive care benefits will not be provided for BRCA testing unless you receive genetic counseling and evaluation prior to the test, and scientifically valid screening measures are used for the evaluation, and the results support BRCA testing. See page 19 for information about prior approval.
Eligible members must meet at least one of the following criteria:
- Members who have a personal history of breast, ovarian, fallopian tube, peritoneal, pancreatic and/or prostate cancer, who have not received BRCA testing, when genetic counseling and evaluation using scientifically valid measures (see above) supports BRCA testing
- Members who have not been diagnosed with breast, ovarian, fallopian tube, peritoneal, pancreatic, and/or prostate cancer who meet at least one of the following family history criteria (see next page for members of Ashkenazi Jewish heritage):
- Individual from a family with a known harmful mutation in BRCA1 and/or BRCA2 gene; or
- Two first-degree female relatives with breast cancer, one of whom was diagnosed at age 50 or younger; or
- A combination of three or more first- or second-degree female relatives with breast cancer regardless of age at diagnosis; or
- A first- or second-degree relative with both breast and ovarian cancer at any age; or
- A history of breast cancer in a first- or second-degree female relative, and a history of ovarian, fallopian tube, or primary peritoneal cancer in the same or another female first- or second-degree relative; or
- A first-degree female relative with bilateral breast cancer; or
- A combination of two or more first- or second-degree female relatives with ovarian cancer regardless of age at diagnosis; or
- A history of pancreatic or prostate cancer diagnosed in a first- or second-degree relative; or
- A history of breast cancer in a male relative
- Individual from a family with a known harmful mutation in BRCA1 and/or BRCA2 gene; or
- Members who have a personal history of breast, ovarian, fallopian tube, peritoneal, pancreatic and/or prostate cancer, who have not received BRCA testing, when genetic counseling and evaluation using scientifically valid measures (see above) supports BRCA testing
- Members of Ashkenazi Jewish heritage who have not been diagnosed with breast, ovarian, fallopian tube, peritoneal, pancreatic, and/or prostate cancer must meet one of the following family history criteria:
- Individual from a family with a known harmful mutation in BRCA1 and/or BRCA2 gene; or
- Any first-degree relative with breast or ovarian cancer; or
- A history of pancreatic or prostate cancer diagnosed in a first- or second-degree relative; or
- Two second-degree relatives on the same side of the family with breast or ovarian cancer
- Individual from a family with a known harmful mutation in BRCA1 and/or BRCA2 gene; or
First-degree relatives are defined as: parents, siblings, and children of the member being tested. Second-degree relatives are defined as: grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings (siblings with one shared biological parent) of the member being tested. Relatives may be living or deceased.
- Testing for large genomic rearrangements of the BRCA1 and BRCA2 genes
- Eligible members are age 18 or older; and
- Receive genetic counseling and evaluation prior to the BRCA1 and BRCA2 testing; and
- Meet BRCA testing criteria described above and on page 43.
- Eligible members are age 18 or older; and
Notes:
- Benefits for BRCA testing and testing for large genomic rearrangements of the BRCA1 and BRCA2 genes are limited to one of each type of test per lifetime whether considered a preventive screening or a diagnostic test (see page 40-41 for our coverage of diagnostic BRCA testing).
- Preventive care benefits are not available for surgical removal of breasts, ovaries, or prostate.
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)
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits for Preferred providers. Benefits are not available for BRCA testing performed at Member or Non-member facilities.
Benefit Description
Immunizations limited to the following vaccines (as licensed by the U.S. Food and Drug Administration (U.S. FDA)):
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:
You Pay
Preferred: Nothing (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges (except as noted below)
Notes:
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.
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Genetic testing related to family history of cancer or other disease, except as described on pages 43-44
Note: See page 40 for our coverage of medically necessary diagnostic genetic testing.
- 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
- Group counseling on prevention and reducing health risks
- Self-administered health risk assessments (other than the Blue Health Assessment)
- Screening services requested solely by the member, such as commercially advertised heart scans, body scans, and tests performed in mobile traveling vans
- Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel
- Immunizations, boosters, and medications for travel or work-related exposure. Medical benefits may be available for these services.
You Pay
All charges
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List Item: |
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preventative |
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adult |
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preventive |
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exams |
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calendar |
|
counseling |
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prevention |
|
reducing |
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Chest |
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X-ray |
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EKG |
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urinalysis |
|
panel |
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metabolic |
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CBC |
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Fasting |
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lipoprotein |
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cholesterol |
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LDL |
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HDL |
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triglycerides |
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diabetes |
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hepatitis |
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mellitus |
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alcohol |
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substance |
|
drug |
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smoking |
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tabacco |
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e-cigarettes |
|
vape |
|
vaping |
|
cessation |
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chlamydial |
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gonorrhea |
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human |
|
immunodeficiency |
|
virus |
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HIV |
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syphilis |
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tuberculosis |
|
helth |
|
risk |
|
assessment |
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HRA |
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colorectal |
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cancer |
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fecal |
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colonoscopy |
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colonoscopies |
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Sigmoidoscopy |
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barium |
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enema |
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prostate |
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specific |
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antigen |
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PSA |
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pap |
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cervix |
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papillomavirus |
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cervical |
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mammograms |
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mammography |
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low-dose |
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CT |
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lung |
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osteoporosis |
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ultrasound |
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abdominal |
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aortic |
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aneurysm |
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nutritional |
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hereditary |
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breast |
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ovary |
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ovarian |
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BRCA |
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genetic |
|
evaluation |
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fallopian |
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peritoneal |
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pancreatic |
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diagnosed |
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diagnosis |
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ashkenazi |
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mutation |
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vaccine |
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herpes |
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zoster |
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influenza |
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measles |
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mumps |
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rubella |
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meningococcal |
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pneumococcal |
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tetanus |
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diphtheria |
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Pertussis |
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Varicella |
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MMR |
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dTAP |
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chickenpox |
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injections |
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laboratory |
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lab |
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scans |
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immunizations |
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boosters |
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travel |
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work-related |
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exposure |
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disorder |
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treatent |
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BRCA1 |
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BRCA2 |