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 43
 
Benefit Description

Preventive Care, Adult (cont.)

 
  • 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
See previous page
 
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:

 
  • 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

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.
 
Preventive Care, Adult - continued on next page