2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(e). Mental Health and Substance Use Disorder Benefits
Outpatient Hospital or Other Covered Facility
Section 5. Benefits
Section 5(e). Mental Health and Substance Use Disorder Benefits
Outpatient Hospital or Other Covered Facility
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefit Description
Outpatient Hospital or Other Covered Facility
Outpatient services provided and billed by a covered facility
Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: $35 copayment per day per facility
Member/Non-member: You pay all charges
Benefit Description
Outpatient Hospital or Other Covered Facility
Outpatient services provided and billed by a covered facility
Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here.
- Individual psychotherapy
- Group psychotherapy
- Pharmacologic (medication) management
- Partial hospitalization
- Intensive outpatient treatment
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: $35 copayment per day per facility
Member/Non-member: You pay all charges
Benefit Description
Outpatient services provided and billed by a covered facility
Note: A residential treatment center is a covered facility for outpatient care (see Section 10, Definitions, for more information). We cover inpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers, other than room and board and inpatient physician care, at the levels shown here.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: Nothing
Member/Non-member: Nothing
Outpatient services provided and billed by a covered facility
- Diagnostic tests
- Psychological testing
Note: A residential treatment center is a covered facility for outpatient care (see Section 10, Definitions, for more information). We cover inpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers, other than room and board and inpatient physician care, at the levels shown here.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 35% of the Plan allowance (deductible applies)
Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: Nothing
Member/Non-member: Nothing