2025 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 65
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 65
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
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.
- 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.
- YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3 to be sure which services require precertification.
- Note: Observation services are billed as outpatient facility care. Benefits for observation services are provided at the outpatient facility benefit levels described in this section. See Section 10, Definitions, for more information about these types of services.
- YOU MUST GET PRIOR APPROVAL for services such as the following: surgery for severe obesity and oral maxillofacial surgeries/surgery on the jaw, cheeks, lips, tongue, roof and floor of the mouth, and related procedures.
- YOU MUST GET PRIOR APPROVAL for gender affirming surgery. See Section 3 for prior approval and Section 5(b) for the surgical benefit.
- When PRIOR APPROVAL IS REQUIRED for a surgical procedure and the surgery is performed on an inpatient basis, YOU MUST ALSO GET PRECERTIFICATION for the inpatient admission.
- You should be aware that some Non-preferred (non-PPO) professional providers may provide services in Preferred (PPO) facilities.
- You must use Preferred providers in order to receive benefits. See Section 3 for the exceptions to this requirement.
- You are responsible for the applicable cost-sharing amounts for care performed and billed by Preferred professional providers in the outpatient department of a Preferred hospital.
- You are responsible for the applicable cost-sharing amounts for care performed and billed by Preferred professional providers in the outpatient department of a Preferred hospital.
- 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 the facility (i.e., hospital or surgical center) or ambulance service, for your inpatient or outpatient surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are listed in Sections 5(a) or 5(b).
- The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family enrollment). We state whether or not the calendar year deductible applies for each benefit listed in this section.
- 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 or are enrolled in the FEP Medicare Prescription Drug Program. See Section 5(f) for information about 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.