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 49
 
Benefit Description

Maternity Care (cont.)

 
  • See page 135 for our payment for inpatient stays resulting from an emergency delivery at a hospital or other facility not contracted with your Local Plan.
     
  • When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in his or her own right. Regular medical or surgical benefits apply rather than maternity benefits.
     
  • See page 60 for our payment levels for circumcision.
 
Benefit Description
  • Breast pump kit, limited to one of the two kits listed below, per calendar year, for members who are pregnant and/or nursing
     
    • Ameda Manual pump kit
or
 
  • Ameda Double Electric pump kit

    Note: The breast pump kit will include a supply of 150 Ameda milk storage bags. You may order Ameda milk storage bags, limited to 150 bags every 90 days, even if you own your own breast pump.
Note: Benefits for the breast pump kit and milk storage bags are only available when you order them through CVS Caremark by calling 800-262-7890.

You Pay
Nothing
 
Benefit Description

Not covered:
  • Procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
     
  • Genetic testing/screening of the baby’s father (see page 40 for our coverage of medically necessary diagnostic genetic testing)
     
  • Childbirth preparation, Lamaze, and other birthing/parenting classes
     
  • Breast pumps and milk storage bags except as stated above
     
  • Breastfeeding supplies other than those contained in the breast pump kit described above including clothing (e.g., nursing bras), baby bottles, or items for personal comfort or convenience (e.g., nursing pads)
     
  • Tocolytic therapy and related services provided on an outpatient basis
     
  • Maternity care for members not enrolled in the Service Benefit Plan

You Pay
All charges
 
Benefit Description

Family Planning
A range of voluntary family planning services for women, limited to:
  • Contraceptive counseling
  • Diaphragms and contraceptive rings
  • Injectable contraceptives
  • Intrauterine devices (IUDs)
  • Implantable contraceptives
  • Tubal ligation or tubal occlusion/tubal blocking procedures only

You Pay
Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating): You pay all charges
 
Family Planning - continued on next page