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
Page 76
 
Benefit Description

Maternity – Facility (cont.)

Not covered:

 
  • Breast pumps and milk storage bags except as stated on page 49
     
  • Breastfeeding supplies other than those contained in the breast pump kit described on page 49 including clothing (e.g., nursing bras), baby bottles, or items for personal comfort or convenience (e.g., nursing pads)
     
  • Childbirth preparation, Lamaze, and other birthing/parenting classes
     
  • Doula, birth companion, and similar supporter
     
  • Genetic testing/screening of the baby’s father (see page 40 for our coverage of medically necessary diagnostic genetic testing)
     
  • Genetic testing not specifically stated as covered on pages 43-44
     
  • Maternity care for members not enrolled in this Plan
     
  • Personal comfort items, such as guest meals and beds, telephone, television, beauty and barber services
     
  • Private duty nursing
     
  • 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
     
  • Tocolytic therapy and related services provided on an outpatient basis

You Pay
All charges
 
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

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member/Non-member): You pay all charges
 
Outpatient Hospital or Ambulatory Surgical Center - continued on next page