2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Preventive Care, Adult
Section 5. Benefits
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Preventive Care, Adult
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
Preventive Care, Adult
Benefits are provided for preventive care services for adults age 22 and over.
Covered services include:
Preventive care benefits for each of the services listed below are limited to one per calendar year.
The following preventive services are covered at the time intervals recommended at each of the links below.
Note: We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year. If you receive both preventive and diagnostic services from your Provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
Note: Unless otherwise noted, the benefits listed under Preventive Care, Adult, do not apply to children up to age 22. (See benefits under Preventive Care, Child, this Section.)
Note: See Section 5(b) for the benefits available for the surgical removal of breast, ovaries, or prostate when screening reveals a BRCA mutation; preventive care benefits are not available.
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance and deductible.
Standard Option - You Pay
Preferred: Nothing (no deductible)
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Note: We waive your deductible and coinsurance amount for services billed by Participating/Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: Nothing
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
Participating/Non-participating: You pay all charges (except as noted below)
Note: For services billed by Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Note: Benefits are not available for visits/exams for preventive care, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Note: We provide benefits for services billed by Participating/Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.
Benefit Description
Preventive Care, Adult
Benefits are provided for preventive care services for adults age 22 and over.
Covered services include:
- Counseling on prevention and reducing health risks
- Nutritional counseling
Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
- Visits/exams for preventive care
Note: See the definition of Preventive Care, Adult, in Section 10 for included health screening services.
Preventive care benefits for each of the services listed below are limited to one per calendar year.
- Administration and interpretation of a Health Risk Assessment (HRA) questionnaire (see Definitions.)
Note: As a member of the Service Benefit Plan, you have access to the Blue Cross and Blue Shield HRA, called the “Blue Health Assessment” questionnaire. See Section 5(h) for complete information.
- Basic or comprehensive metabolic panel test
- CBC
- Cervical cancer screening tests
- Human papillomavirus (HPV) tests of cervix
- Pap tests of the cervix
- Human papillomavirus (HPV) tests of cervix
- Colorectal cancer tests, including:
- Colonoscopy, with or without biopsy (see Section 5(b) for our payment levels for diagnostic colonoscopies)
- CT colonography
- DNA analysis of stool samples
- Double contrast barium enema
- Fecal occult blood test
- Sigmoidoscopy
- Colonoscopy, with or without biopsy (see Section 5(b) for our payment levels for diagnostic colonoscopies)
- Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or triglycerides)
- General health panel
- Prostate cancer tests – Prostate Specific Antigen (PSA)
- Screening for chlamydial infection
- Screening for diabetes mellitus
- Screening for gonorrhea infection
- Screening for human immunodeficiency virus (HIV)
- Screening mammograms, including mammography using digital technology
- Ultrasound for abdominal aortic aneurysm for adults, ages 65 to 75, limited to one screening per lifetime
- Urinalysis
The following preventive services are covered at the time intervals recommended at each of the links below.
- Immunizations such as COVID-19, Pneumococcal, influenza, shingles, tetanus/Tdap and human papillomavirus (HPV). For a complete list of immunizations, go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules.
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to certain age ranges, frequencies, and/or other patient-specific indications, including gender.
- USPSTF A and B recommended screenings such as cancer, osteoporosis, depression, and high blood pressure. For a complete list of covered A and B recommendation screenings and age and frequency limitations, go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.
- Well woman care such as gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services, go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/.
- To build your personalized list of preventive services, go to https://health.gov/myhealthfinder.
Note: We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year. If you receive both preventive and diagnostic services from your Provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
Note: Unless otherwise noted, the benefits listed under Preventive Care, Adult, do not apply to children up to age 22. (See benefits under Preventive Care, Child, this Section.)
Note: See Section 5(b) for the benefits available for the surgical removal of breast, ovaries, or prostate when screening reveals a BRCA mutation; preventive care benefits are not available.
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance and deductible.
Standard Option - You Pay
Preferred: Nothing (no deductible)
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Note: We waive your deductible and coinsurance amount for services billed by Participating/Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred: Nothing
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
Participating/Non-participating: You pay all charges (except as noted below)
Note: For services billed by Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Note: Benefits are not available for visits/exams for preventive care, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Note: We provide benefits for services billed by Participating/Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Self-administered health risk assessments (other than the Blue Health Assessment)
- Screening services requested solely by the member, such as commercially advertised heart scans, body scans, and tests performed in mobile traveling vans
- Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
- Immunizations, boosters, and medications for travel or work-related exposure. Medical benefits may be available for these services.
- Phone consultations and online medical evaluation and management services (telemedicine) for preventive services, except as previously noted in this section for nutritional counseling.
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges