2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services


Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it does not apply.
 
Benefit Description

Outpatient Hospital or Ambulatory Surgical Center
Outpatient surgical and treatment services performed and billed by a facility, such as:

 
  • Operating, recovery, and other treatment rooms
     
  • Anesthetics and anesthesia services
     
  • Pre-surgical testing performed within one business day of the covered surgical services
     
  • Chemotherapy and radiation therapy
     
  • Colonoscopy, with or without biopsy

    Note: Preventive care benefits apply to the facility charges for your first covered colonoscopy of the calendar year (see page 42). We provide diagnostic benefits for services related to subsequent colonoscopy procedures in the same year.

     
  • Intravenous (IV)/infusion therapy
     
  • Renal dialysis
     
  • Visits to the outpatient department of a hospital for non-emergency treatment services
     
  • Diabetic education
     
  • Administration of blood, blood plasma, and other biologicals
     
  • Blood and blood plasma, if not donated or replaced, and other biologicals
     
  • Dressings, splints, casts, and sterile tray services
     
  • Facility supplies for hemophilia home care
     
  • Other medical supplies, including oxygen
     
  • Surgical implants
     
  • Cardiac rehabilitation
     
  • Observation services

    Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. Please refer to Section 5(a) for services billed by professional providers during an observation stay and page 73 for information about benefits for inpatient admissions.

     
  • Pulmonary rehabilitation
     
  • Hospital-based clinic visits
     
  • Outpatient hospital services and supplies related to:
     
    • Treatment of children up to age 22 with severe dental caries.
       
    • Dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(g), Dental Benefits, page 104.

Notes:

 
  • See pages 84-86 for our payment levels for care related to a medical emergency or accidental injury.
     
  • See pages 49-50 for our coverage of family planning services.
     
  • See page 79 for outpatient drugs, medical devices, and durable medical equipment billed for by a facility.
     
  • See page 74 for maternity care provided in an outpatient facility.

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member/Non-member): You pay all charges
 
Benefit Description
Outpatient diagnostic testing performed and billed by a facility, such as:

 
  • Angiographies
     
  • Bone density tests
     
  • CT scans*/MRIs*/PET scans*
     
  • Genetic testing*

    Note: We cover specialized diagnostic genetic testing billed for by a facility, such as the outpatient department of a hospital, as shown here. See pages 43-44 for coverage criteria and limitations.

     
  • Nuclear medicine
     
  • Sleep studies
     
  • Cardiovascular monitoring
     
  • EEGs
     
  • Ultrasounds
     
  • Neurological testing
     
  • X-rays (including set-up of portable X-ray equipment)
     
  • EKGs
     
  • Laboratory tests and pathology services

Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, see Maternity – Facility, page 74 in this Section.

*Prior approval is required.

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member/Non-member):

 
  • Member: 30% of the Plan allowance
     
  • Non-member: 30% of the Plan allowance, plus any difference between our allowance and the billed amount
 
Outpatient treatment and therapy services performed and billed by a facility, limited to:
 
  • Cognitive rehabilitation therapy limited to 25 visits per person per calendar year
     
  • Physical therapy, occupational therapy, and speech therapy limited to 25 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
     
  • Manipulative treatment and acupuncture services, limited to a combined 10 visits per person:

    Notes:

     
    • We provide benefits for manipulative treatment and acupuncture services as described on page 57.
       
    • See page 71 for our coverage of acupuncture when provided as anesthesia for covered surgery.
       
    • See page 75 for our coverage of acupuncture when provided as anesthesia for covered maternity care.

Note: The limitations listed above are a combined total regardless of the type of covered provider or facility billing for the services.

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

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

Note: You pay 30% of the Plan allowance for supplies or drugs administered or obtained in connection with your care. (See page 131 for more information about “agents.”)
 
Benefit Description
Outpatient treatment services performed and billed by a facility, are limited to:

 
  • Outpatient applied behavior analysis* (ABA) for an autism spectrum disorder performed and billed by a facility limited to 200 hours per person, per calendar year.

    Note: The limitations listed is a combined total regardless of the type of covered provider or facility billing for the services.

*Prior approval is required, see pages 19-22 for prior approval requirements.

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member/Non-member): You pay all charges
 
Benefit Description
Outpatient adult preventive care performed and billed by a facility, limited to:

 
  • Visits/exams for preventive care, screening procedures, and routine immunizations described on pages 41-46
     
  • Cancer screenings listed on page 42 and ultrasound screening for abdominal aortic aneurysm
     
Notes:
 
  • See pages 43-44 for our coverage requirements for preventive BRCA testing.
     
  • See pages 46-47 for our payment levels for covered preventive care services for children billed for by facilities and performed on an outpatient basis.

You Pay
Preferred facilities: Nothing (no deductible)

Non-preferred facilities (Member/Non-Member): Nothing for cancer screenings and ultrasound screening for abdominal aortic aneurysm

Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Non-preferred (Member/Non-member) facilities.
 
Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:
 
  • Prescribed drugs and medications

    Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage. See page 95 for information about specialty drug fills from a Preferred pharmacy.

     
  • Orthopedic and prosthetic devices
     
  • Durable medical equipment
     
  • Surgical implants
     
  • Oral and transdermal contraceptives

    Note: We waive your cost-share for generic oral and transdermal contraceptives when you purchase them at a Preferred retail pharmacy; see Section 5(f) page 97.

You Pay
Preferred facilities: 30% of the Plan allowance

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

List Item:

outpatient
hospital
ambulatory
surgical
operation
operating
recovery
treatment
anesthetics
anesthesia
acupuncture
pre-surgical
resting
chemotherapy
radiation
therapy
colonoscopy
biopsy
intravenous
IV
infusion
dialysis
non-emergency
diabetic
education
diabetes
dressings
splints
casts
blood
plasma
biologicals
hemophilia
home
supplies
medical
oxygen
implants
accidental
emergency
family
planning
hospital-based
out-of-pocket
maternity
birthing
facilities
cost-share
drugs
DME
durable
equipment
dental
non-dental
observation
angiographies
arteriography
bone
density
tests
CT
scans
MRIs
PET
genetic
nuclear
sleep
studies
cardiovascular
monitoring
EEGs
ultrasounds
neurological
x-rays
cognitive
rehabilitation
physical
occupational
speech
manipulative
treatments
cardiac
pulmonary
behavior
behaviour
analysis
autism
spectrum
disorder
laboratory
lab
opathology
EKGs
visits
preventative
screening
immunizations
cancer
abdominal
aortic
aneurysm
BRCA
prescribed
prescription
orthopedic
prosthetic
devices
renal
breast
applied
ABA