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 38
Important things you should keep in mind about these benefits:
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Please refer to Section 3, How You Get Care, for information on covered professional providers and other healthcare professionals.
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
  • We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will find that some benefits are listed in more than one Section of the brochure. This is because how they are paid depends on what type of provider or facility bills for the service.
  • The services listed in this Section are for the charges billed by a physician or other healthcare professional for your medical care. See Section 5(c) for charges associated with the facility (i.e., hospital or other outpatient facility, etc.).
  • Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drugs when obtained from a covered provider other than a pharmacy under the pharmacy benefit. You must use a Preferred pharmacy, thereafter. This benefit limitation does not apply if you have primary Medicare Part B coverage. See page 95 for information about Tier 2 specialty drug fills from a Preferred pharmacy. Medications restricted under this benefit are available on our FEP Blue Focus Specialty Drug List. Visit www.fepblue.org/specialtypharmacy or call us at 888-346-3731.
  • The calendar year deductibles: $500 per person ($1,000 per Self Plus One or Self and Family enrollment). The calendar year deductible applies to many of the benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • You must use Preferred providers in order to receive benefits. See below and page 18 for the exceptions to this requirement.
  • We provide benefits at Preferred benefit levels for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician’s office). You are responsible for any difference between our payment and the billed amount.
  • You should be aware that some Non-preferred professional providers may provide services in Preferred inpatient facilities.
  • There is a $10 visit copayment for each of the first 10 visits to a professional provider per calendar year. This applies to a combined total for medical and mental health and substance use disorder visits.
  • We waive the cost-share for the first 2 visits for telehealth per calendar year. This applies to a combined total for treatment of minor acute conditions, dermatology care, and mental health and substance use disorder conditions. (See pages 39 and 88.)
  • If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services. This includes applicable cost-share for diagnostic procedures such as an injection, laboratory, and X-ray services.
  • An incentive award is available for those members (member and/or Spouse over age 18) who receive an annual routine physical in 2020. Please see Section 5(h), page 108, for more information.