2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 81
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 81
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage, or are enrolled in the Medicare Prescription Drug Program.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 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 facilities: 30% of the Plan allowance
Note: You may also be responsible for paying a copayment per day per facility for other outpatient services listed in this section.
Member/Non-member facilities: You pay all charges
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:
- Prescribed drugs
- Orthopedic and prosthetic devices
- Durable medical equipment
- Surgical implants
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage, or are enrolled in the Medicare Prescription Drug Program.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 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 facilities: 30% of the Plan allowance
Note: You may also be responsible for paying a copayment per day per facility for other outpatient services listed in this section.
Member/Non-member facilities: You pay all charges
Benefit Description
Blue Distinction® Specialty Care
We provide enhanced benefits for covered inpatient facility services related to the surgical procedures listed below, when the surgery is performed at a facility designated as a Blue Distinction Center for Knee and Hip Replacement, Blue Distinction Center for Spine Surgery, or Blue Distinction Center for Comprehensive Bariatric Surgery.
Note: You must precertify your hospital stay and verify your facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to your admission at the customer service phone number listed on the back of your ID card for assistance.
Standard Option - You Pay
Blue Distinction Center: $150 per admission copayment for unlimited days (no deductible)
Basic Option - You Pay
Blue Distinction Center: $100 per day copayment up to $500 per admission for unlimited days
Blue Distinction® Specialty Care
We provide enhanced benefits for covered inpatient facility services related to the surgical procedures listed below, when the surgery is performed at a facility designated as a Blue Distinction Center for Knee and Hip Replacement, Blue Distinction Center for Spine Surgery, or Blue Distinction Center for Comprehensive Bariatric Surgery.
- Bariatric surgeries covered are:
- Roux-en-Y gastric bypass
- Laparoscopic adjustable gastric banding
- Sleeve gastrectomy
- Biliopancreatic bypass with duodenal switch
- Roux-en-Y gastric bypass
- Total hip replacement or revision
- Total knee replacement or revision
- Spine surgery, limited to:
- Cervical discectomy
- Thoracic discectomy
- Laminectomy
- Laminoplasty
- Spinal fusion
- Cervical discectomy
Note: You must precertify your hospital stay and verify your facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to your admission at the customer service phone number listed on the back of your ID card for assistance.
Standard Option - You Pay
Blue Distinction Center: $150 per admission copayment for unlimited days (no deductible)
Basic Option - You Pay
Blue Distinction Center: $100 per day copayment up to $500 per admission for unlimited days
Blue Distinction® Specialty Care - continued on next page