2025 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 40
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 40
Benefit Description
Preventive Care, Adult (cont.)
The following preventive services are covered at the time interval recommended at each of the links below.
Notes:
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 in Section 3 for an exception, you pay:
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Note: 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).
Note: Many Preferred retail pharmacies participate in our vaccine network. See Section 5(f) for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Preventive Care, Adult (cont.)
- Urinalysis
The following preventive services are covered at the time interval recommended at each of the links below.
- Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC) based on the Advisory Committee on Immunization Practices (ACIP) schedule such as COVID-19, Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations, go to the website at https://www.cdc.gov/vaccines/imz-schedules/index.html.
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to certain age ranges, frequencies, and/or other patient-specific indications, including gender.
- U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, and high blood pressure. For a complete list of covered A and B recommendation screenings and age and frequency limitations, go to the website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
- Well woman care such as gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services, go to the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines
- To build your personalized list of preventive services, go to https://health.gov/myhealthfinder
Notes:
- We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year. If you receive both preventive and diagnostic services from your Provider on the same day, you are responsible for paying your cost-share for the diagnostic services. Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance and deductible.
- Unless otherwise noted, the benefits discussed under Preventive Care, Adult, do not apply to individuals aged 21 and under. (See benefits under Preventive Care, Child, in this section.)
- See Section 5(b) for the benefits available for the surgical removal of breast, ovaries, or prostate when screening reveals a BRCA mutation; preventive care benefits are not available.
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 in Section 3 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)
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Note: 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).
Note: Many Preferred retail pharmacies participate in our vaccine network. See Section 5(f) for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Preventive Care, Adult - continued on next page