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 50
 
Benefit Description

Family Planning (cont.)

Family planning services for men, limited to:

 
  • Vasectomy
Notes:
 
  • We also provide benefits for professional services associated with tubal ligation/occlusion/blocking procedures, vasectomy, and with the fitting, insertion, or removal of the contraceptives as shown on the previous page.
     
  • 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.

You Pay
See previous page
 
Benefit Description
 
  • 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: 30% of the Plan allowance

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

Not covered:

 
  • Reversal of voluntary surgical sterilization
     
  • Contraceptive devices not described above
     
  • Over-the-counter (OTC) contraceptives, except as described in Section 5(f)

You Pay
All charges
 
Benefit Description

Reproductive Services

Diagnosis of infertility, limited to:

 
  • Diagnostic services
  • Laboratory tests
  • Diagnostic tests
  • Agents, drugs, and/or supplies administered or obtained in connection with your care
Note: See Section 5(a) for covered labs, diagnostic tests, and X-rays.

You Pay
Preferred: 30% of the Plan allowance

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: 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

Not covered: The services listed below are not covered as treatments for infertility or as alternatives to conventional conception:

 
  • Assisted reproductive technology (ART) and assisted insemination procedures, including but not limited to:
    • Artificial insemination (AI)
    • In vitro fertilization (IVF)
    • Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT)
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intracytoplasmic sperm injection (ICSI)
    • Intrauterine insemination (IUI)

You Pay
All charges
 
Reproductive Services - continued on next page