FEP Blue Focus
the limit is $8,500 for self only or $17,000 for self plus one or family when you use Preferred Providers
What is Catastrophic Amount limit?
2- Evaluations, Prophys (cleanings), fluoride per calendar year, Palliative treatment, intra oral complete series
What is the Dental Benefit?
Continuous passive motion (CPM) devices are a part of this benefit
What is Durable Medical Equipment (DME)?
Personal comfort items, such as guest meals and beds, telephone, television, beauty and barber services
What is not covered?
Excision of tumors and cyst of the jaws, cheeks, lips, tongue, roof and floor of mouth when pathological examination is necessary
What is a type of Oral and Maxillofacial Surgery?
$500 individual $1000 self plus one or family coverage
What is deductible?
$350 individual/ $700 family
What is the Standard calendar year deductible?
These benefits are limited to a combined total of 20 visits per person, per calendar year.
What is Chiropractic?
Osteopathic manipulative treatment to any body region
Chiropractic spinal and/or extraspinal manipulative treatment.
Inpatient facility copay for perferred Basic option
What is $250 copay, per day, up to a $1500 maximum per admission. Benefits are provided at 100% of plan allowance for unlimited days.
Shoes (including diabetic shoes), over- the- counter orthotics, arch supports, heel pads and heel cups
What is not covered under Orthopedic and Prosthetic Devices?
This type of weight loss surgery/procedure must be performed at a Blue Distinction Center.
What is- Procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co-morbidities; eligible members must be age 16 or over and the procedure must be performed at a facility designated as a Blue Distinction Center for Comprehensive Bariatric Surgery. ?
Provocative food testing
What is not covered for Allergy Care?
For PPO facilities, what benefit is the Patient responsible for $250 copay per admission. Benefits are provided at 100% of plan allowance.
What is Maternity Care facility benefit
Inpatient Facility non-ppo Copay Standard Option
What is Patient is responsible for $450 copay per admission for unlimited days plus 35% of plan allowance (no deductible), and the difference between our allowance and the billed amount. ?
1st calendar year Colonoscopy benefits with PPO provider all options
What is covered at 100% of plan allowance?
After 10th visit: Patient is responsible for 30% of plan allowance, after deductible of $500 ind/$1000 self plus one or family
What is Office visit benefit?
(Can also be manipulative treatment and acupuncture, mental health substance use disorder professional)
Vasectomy- Benefits are provided at 100% of the plan allowance, for all eligible services (no deductible)
What is Family Planning PPO Benefit?
Smoking and tobacco cessation treatment and classes; counseling for smoking and tobacco use cessation
What is the basic education classes and Programs?
Benefits are provided for up to 30 consecutive days in a facility licensed as an inpatient ______ facility. The member does not have to be enrolled in a home _____ care program to be eligible for the first inpatient stay. However, the member must be enrolled in a home _____ care program in order to receive benefits for subsequent inpatient stays.
WHAT WORD FILLS IN THE BLANKS?
HOSPICE
Hearing aid for adult benefits Standard
What is Hearing aids for adults age 22 and over, limited to $2500 every 5 calendar years?
Benefits are limited to 25 visits per person, per calendar year for ______, _______, or ______, or a combination of all three
What is Physical, occupational, or speech therapy?
We cover one year of sperm and egg storage for individuals facing iatrogenic infertility, once per lifetime.
What benefit is this?
What is Reproductive benefit?
Benefits for this inpatient care nursing facility is not covered under basic option.
What is EXTENDED CARE BENEFITS/SKILLED NURSING CARE FACILITY ? (SNF)
A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located AFTER admission.
True or False?
FALSE, must be obtained PRIOR to admission.
Under FEP Blue Focus, these 3 tests DO require prior approval.
What are CT, MRI and PET scans?