2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2024
Page 166
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2024
Page 166
Prescription drugs
Retail Pharmacy Program:
Dental care
PPO: $35 copayment per evaluation (exam, cleaning, and X-rays); most services limited to 2 per year; sealants for children up to age 16; $35 copayment for associated oral evaluations required due to accidental injury; regular benefits for covered oral and maxillofacial surgery
Non-PPO: You pay all charges
124
Wellness and other special features: Health Tools; Blue Health Assessment; MyBlue® Customer eService; National Doctor and Hospital Finder; Healthy Families; travel benefit/services overseas; Care Management Programs; and Flexible benefits option
See Section 5(h).
125-129
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
33-34
Retail Pharmacy Program:
- PPO: $15 generic/($10 if you have primary Medicare Part B)/$60 Preferred brand-name per prescription ($50 if you have primary Medicare Part B)/60% coinsurance ($90 minimum) for non-preferred brand-name drugs (50% ($60 minimum) if you have primary Medicare Part B)
- Non-PPO: You pay all charges
- $85 preferred specialty drug for a purchase of up to a 30-day supply; $110 non-preferred specialty drug for a purchase of up to a 30-day supply
- $20 generic/$100 Preferred brand-name/$125 non-preferred brand-name per prescription; up to a 90-day supply
Dental care
PPO: $35 copayment per evaluation (exam, cleaning, and X-rays); most services limited to 2 per year; sealants for children up to age 16; $35 copayment for associated oral evaluations required due to accidental injury; regular benefits for covered oral and maxillofacial surgery
Non-PPO: You pay all charges
124
Wellness and other special features: Health Tools; Blue Health Assessment; MyBlue® Customer eService; National Doctor and Hospital Finder; Healthy Families; travel benefit/services overseas; Care Management Programs; and Flexible benefits option
See Section 5(h).
125-129
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
- Self Only: Nothing after $6,500 (PPO) per contract per year
- Self Plus One: Nothing after $13,000 (PPO) per contract per year
- Self and Family: Nothing after $13,000 (PPO) per contract per year; nothing after $6,500 (PPO) per individual per year
Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
33-34