2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 53
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 53
Benefit Description
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy (cont.)
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy (cont.)
Not covered:
- Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay
- Maintenance or palliative rehabilitative therapy
- Exercise programs
- Equine therapy and hippotherapy (exercise on horseback)
- Massage therapy
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Hearing Services (Testing, Treatment, and Supplies)
Note: For our coverage of hearing aids and related services, see Orthopedic and Prosthetic Devices in this section.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $45 copayment per visit
Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.
Participating/Non-participating: You pay all charges
Hearing Services (Testing, Treatment, and Supplies)
- Hearing tests related to illness or injury
- Testing and examinations for prescribing hearing aids
Note: For our coverage of hearing aids and related services, see Orthopedic and Prosthetic Devices in this section.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $45 copayment per visit
Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care.
Participating/Non-participating: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Routine hearing tests
- Hearing aids (except as described later in this section)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Vision Services (Testing, Treatment, and Supplies)
Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:
Note: Benefits are provided for refractions 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 previously described.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Added, 3/13/2024
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Vision Services (Testing, Treatment, and Supplies)
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
Note: Benefits are provided for refractions 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 previously described.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Added, 3/13/2024
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Vision Services (Testing, Treatment, and Supplies) - continued on next page