2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover
Page 113
The exclusions in this Section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3, You need prior Plan approval for certain services.

We do not cover the following:

  • Services, drugs, or supplies you receive while you are not enrolled in this Plan.
  • Services, drugs, or supplies that are not medically necessary.
  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice in the United States.
  • Services, drugs, or supplies billed by Preferred and Member facilities for inpatient care related to specific medical errors and hospital-acquired conditions known as Never Events (see definition on page 134).
  • Experimental or investigational procedures, treatments, drugs, or devices (see Section 5(b) regarding transplants).
  • Services, drugs, or 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.
  • Services, drugs, or supplies related to sexual dysfunction or sexual inadequacy (except for surgical placement of penile prostheses to treat erectile dysfunction and gender reassignment surgeries specifically listed as covered).
  • Travel expenses except as specifically provided for covered transplants performed in a Blue Distinction Center for Transplant (see page 70).
  • Services, drugs, or supplies you receive from a provider or facility barred or suspended from the FEHB Program.
  • Services, drugs, or supplies you receive in a country sanctioned by the Office of Foreign Assets Control (OFAC) of the U.S. Department of the Treasury, from a provider or facility not appropriately licensed to deliver care in that country.
  • Services or supplies for which no charge would be made if the covered individual had no health insurance coverage.
  • Services, drugs, or supplies you receive without charge while in active military service.
  • Charges which the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/or B (see page 128), doctor’s charges exceeding the amount specified by the Department of Health & Human Services when benefits are payable under Medicare (limiting charge, see page 129), or state premium taxes however applied.
  • Prescriptions, services or supplies ordered, performed, or furnished by you or your immediate relatives or household members, such as spouse, parents, children, brothers, or sisters by blood, marriage, or adoption.
  • Services or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs; oxygen; and physical, speech, and occupational therapy provided by a qualified professional therapist on an outpatient basis are covered subject to Plan limits.
  • Services, drugs, or supplies you receive from noncovered providers.
  • Services, drugs, or supplies you receive for cosmetic purposes.
  • Services, drugs, or supplies for the treatment of obesity, weight reduction, or dietary control, except for office visits, diagnostic tests, and procedures and services for the treatment of morbid obesity listed on pages 61-62.
  • Services you receive from a provider that are outside the scope of the provider’s licensure or certification.
  • Any dental or oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or continued use of dentures, except as specifically described in Section 5(g), Dental Benefits, and Section 5(b) under Oral and Maxillofacial Surgery.
  • Dental and orthodontic services, except for treatment of accidental injury as described on page 103, or oral surgery as described on page 64.