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
Preventive Care, Adult

 

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Benefit Description

Preventive Care, Adult
Benefits are provided for preventive care services for adults age 22 and over.

Covered services include:
  • Counseling on prevention and reducing health risks
     
  • Nutritional counseling
    Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
     
  • Visits/exams for preventive care
    Note: See the definition of Preventive Care, Adult, for included health screening services.

Preventive care benefits for each of the services listed below are limited to one per calendar year.
  • Administration and interpretation of a Health Risk Assessment (HRA) questionnaire (see Definitions)
    Note: As a member of FEP Blue Focus, you have access to the Blue
    Cross and Blue Shield HRA, called the “Blue Health Assessment” questionnaire. See Section 5(h) for more information.
     
  • Basic or comprehensive metabolic panel test
     
  • CBC
     
  • Cervical cancer screening tests
     
    • Human papillomavirus (HPV) tests of the cervix
       
    • Pap tests of the cervix
       
  • Colorectal cancer tests, including:
     
    • Colonoscopy with or without biopsy (see Section 5(b) for our payment levels for diagnostic colonoscopies)
       
    • CT colonography
       
    • DNA analysis of stool samples
       
    • Double contrast barium enema
       
    • Fecal occult blood test
       
    • Sigmoidoscopy
       
  • Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or triglycerides)
     
  • General health panel
     
  • Prostate cancer tests – Prostate Specific Antigen (PSA) test
     
  • Screening for chlamydial infection
     
  • Screening for diabetes mellitus
     
  • Screening for gonorrhea infection
     
  • Screening for human immunodeficiency virus (HIV)
     
  • Screening mammograms, including mammography using digital technology
     
  • Ultrasound for abdominal aortic aneurysm for adults, ages 65 to 75, limited to one screening per lifetime
     
  • 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.

 

Benefit Description

Obesity counseling, screening and referral to intensive nutrition and behavioral weight-loss therapy, or counseling under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:
 
  • Unlimited nutritional counseling including nutritional counseling via the contracted telehealth provider network
     
  • Unlimited visits for counseling on prevention and reducing health risks
     
  • Unlimited visits for individual and group behavioral counseling for obesity
     
  • Unlimited family-centered programs when medically identified to support obesity prevention and management by an in-network provider.

Notes:
 
  • Benefits are available for anti-obesity medications. See Section 5(f).
     
  • See Section 5(b) for information related to benefits for the surgical treatment of severe obesity.


You Pay
Preferred: Nothing (no deductible)

Non-preferred (Participating/Non-participating): You pay all charges

 

Benefit Description

Not covered:
 
  • Self-administered health risk assessments (other than the Blue Health Assessment)
     
  • Screening services requested solely by the member, such as commercially advertised heart scans, body scans, and tests performed in mobile traveling vans
     
  • Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel
     
  • Immunizations, boosters, and medications for travel or work-related exposure. Medical benefits may be available for these services.
     
  • Phone consultations and online medical evaluation and management services (telemedicine) for preventive services, except as noted earlier for nutritional counseling


You Pay
All charges