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 49
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 49
Benefit Description
Vision Services (Testing, Treatment, and Supplies)
Eye examinations or visits related to a specific medical condition.
You Pay
Preferred: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits described at the beginning of this section)
Preferred provider, visits after the 10th visit: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care.
Vision Services (Testing, Treatment, and Supplies)
Eye examinations or visits related to a specific medical condition.
You Pay
Preferred: $10 copayment (no deductible) per visit up to a combined total of 10 visits per calendar year (benefits combined with visits described at the beginning of this section)
Preferred provider, visits after the 10th visit: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care.
Benefit Description
Diagnostic testing and treatment, such as:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Diagnostic testing and treatment, such as:
- Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21
- Lab, X-ray, and other diagnostic tests performed or ordered by your provider.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
- Refraction, only when the refraction is performed to determine the prescription for the one pair of eyeglasses, replacement lenses, or contact lenses provided per incident as described below.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:
- To correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery;
- If the condition can be corrected by surgery, but surgery is not an appropriate option due to age or medical condition;
- For the nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses, except as described above
- Deluxe eyeglass frames or lens features for eyeglasses or contact lenses such as special coating, polarization, UV treatment, etc.
- Multifocal, accommodating, toric, or other premium intraocular lenses (IOLs) including Crystalens, ReStor, and ReZoom
- Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described above
- LASIK, INTACS, radial keratotomy, and other refractive surgical services
- Refractions, including those performed during an eye examination related to a specific medical condition, except as described above
You Pay
All charges