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 44
 
Benefit Description

Preventive Care, Adult (cont.)


  • Eligible members must meet at least one of the following criteria (continued):
     
  • 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 below for members of Ashkenazi Jewish heritage) (continued):
     
    • A first- or second-degree relative with both breast and ovarian cancer at any age; or
       
    • A history of breast cancer in a first- or second-degree female relative, and a history of ovarian, fallopian tube, or primary peritoneal cancer in the same or another female first- or second-degree relative; or
       
    • A first-degree female relative with bilateral breast cancer; or
       
    • A combination of two or more first- or second-degree female relatives with ovarian cancer regardless of age at diagnosis; or
       
    • A history of pancreatic or prostate cancer diagnosed in a first- or second-degree relative; or
       
    • A history of breast cancer in a male relative
       
 
  • Members of Ashkenazi Jewish heritage who have not been diagnosed with breast, ovarian, fallopian tube, peritoneal, pancreatic, and/or prostate cancer must meet one of the following family history criteria:
     
    • Individual from a family with a known harmful mutation in BRCA1 and/or BRCA2 gene; or
       
    • Any first-degree relative with breast or ovarian cancer; or
       
    • A history of pancreatic or prostate cancer diagnosed in a first- or second-degree relative; or
       
    • Two second-degree relatives on the same side of the family with breast or ovarian cancer

First-degree relatives are defined as: parents, siblings, and children of the member being tested. Second-degree relatives are defined as: grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings (siblings with one shared biological parent) of the member being tested. Relatives may be living or deceased.
 
  • Testing for large genomic rearrangements of the BRCA1 and BRCA2 genes
     
    • Eligible members are age 18 or older; and
       
    • Receive genetic counseling and evaluation prior to the BRCA1 and BRCA2 testing; and
       
    • Meet BRCA testing criteria described above and on page 43.

Notes:
 
  • Benefits for BRCA testing and testing for large genomic rearrangements of the BRCA1 and BRCA2 genes are limited to one of each type of test per lifetime whether considered a preventive screening or a diagnostic test (see page 40-41 for our coverage of diagnostic BRCA testing).
     
  • Preventive care benefits are not available for surgical removal of breasts, ovaries, or prostate.

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Preventive Care, Adult - continued on next page