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 49
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 49
Benefit Description
Reproductive Services
Members meeting our definition of infertility found in Section 10, are eligible for the following reproductive services once prior approval has been obtained:
Correction, 3/13/2024
Note: We also provide the benefits seen here when these services are billed by an outpatient facility. See Section 5(f), Prescription Drug Benefits, for your cost-shares associated with oral/injectable medications for covered AI procedures.
Note: We cover one year of sperm and egg storage, including procurement procedures, only for individuals facing iatrogenic infertility, once per lifetime. We also provide the benefits seen here when billed by a facility. See Section 3, Other services, for prior approval requirements. See Section 10 for our definition of iatrogenic infertility.
Note: See other sections in this brochure for benefits associated with any other services performed to diagnose and treat the cause of infertility.
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: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Reproductive Services
Members meeting our definition of infertility found in Section 10, are eligible for the following reproductive services once prior approval has been obtained:
- Artificial insemination (AI)
- Intracervical insemination (ICI)
- Intrauterine insemination (IUI)
- Intravaginal insemination (IVI)
- Intracervical insemination (ICI)
Correction, 3/13/2024
Note: We also provide the benefits seen here when these services are billed by an outpatient facility. See Section 5(f), Prescription Drug Benefits, for your cost-shares associated with oral/injectable medications for covered AI procedures.
Note: We cover one year of sperm and egg storage, including procurement procedures, only for individuals facing iatrogenic infertility, once per lifetime. We also provide the benefits seen here when billed by a facility. See Section 3, Other services, for prior approval requirements. See Section 10 for our definition of iatrogenic infertility.
Note: See other sections in this brochure for benefits associated with any other services performed to diagnose and treat the cause of infertility.
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: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Benefit Description
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies), and any amount over the $25,000 maximum
Participating: 35% of the Plan allowance (deductible applies), and any amount over the $25,000 maximum
Non-participating: 35% of the Plan allowance (deductible applies), plus an difference between our allowance and the billed amount, and any amount over the $25,000 annual maximum
Basic Option - You Pay
All charges
Correction, 3/13/2024
Assisted reproductive technologies (ART)
Members meeting our definition of infertility, found in Section 10, are eligible for ART services, limited to $25,000 paid annually.
Note: We also provide the benefits seen here when billed by a facility.
See Section 5(f), Prescription Drug Benefits, for your cost-shares and limitations for drugs associated with IVF.
Note: The covered AI procedures and associated drugs listed in this section, and the prescription drugs associated with ART procedures are not subject to the $25,000 annual maximum.
Note: Prior approval required.
Correction, 3/13/2024
Assisted reproductive technologies (ART)
Members meeting our definition of infertility, found in Section 10, are eligible for ART services, limited to $25,000 paid annually.
Note: We also provide the benefits seen here when billed by a facility.
See Section 5(f), Prescription Drug Benefits, for your cost-shares and limitations for drugs associated with IVF.
Note: The covered AI procedures and associated drugs listed in this section, and the prescription drugs associated with ART procedures are not subject to the $25,000 annual maximum.
Note: Prior approval required.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies), and any amount over the $25,000 maximum
Participating: 35% of the Plan allowance (deductible applies), and any amount over the $25,000 maximum
Non-participating: 35% of the Plan allowance (deductible applies), plus an difference between our allowance and the billed amount, and any amount over the $25,000 annual maximum
Basic Option - You Pay
All charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- All related donor expenses including but not limited to the cost of donor sperm or oocytes
- Fallopian tube ligations and vasectomy reversals
- Services determined to be not medically necessary
- Other services, supplies, or drugs provided to individuals not enrolled in this Plan, including surrogates
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges