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 46
 
Benefit Description

Preventive Care, Adult (cont.)

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
 
Benefit Description

Preventive Care, Child

Benefits are provided for preventive care services for children up to age 22, including services recommended under the Affordable Care Act (ACA) and as described in the Bright Future Guidelines provided by the American Academy of Pediatrics (AAP).

Covered services include:

 
  • Healthy newborn visits and screenings (inpatient or outpatient)
     
  • Visits/exams for preventive care
     
  • Laboratory tests
     
  • Hearing and vision screenings
     
  • Application of fluoride varnish for children through age 5, when administered by a primary care provider (limited to 2 per calendar year)
     
  • Immunizations as licensed by the U.S. Food and Drug Administration (U.S. FDA) limited to the following vaccines:
     
    • Diphtheria, tetanus, pertussis
    • Hemophilus influenza type b (Hib)
    • Hepatitis (types A and B)
    • Human papillomavirus (HPV)
    • Inactivated poliovirus
    • Measles, mumps, rubella
    • Meningococcal
    • Pneumococcal
    • Rotavirus
    • Influenza (flu)
    • Varicella

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)
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.
 
Preventive Care, Child - continued on next page