Section 5(a). Overview

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

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals

Important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Please refer to Section 3, How You Get Care, for information on covered professional providers and other healthcare professionals.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will find that some benefits are listed in more than one Section of the brochure. This is because how they are paid depends on what type of provider or facility bills for the service.
The services listed in this Section are for the charges billed by a physician or other healthcare professional for your medical care. See Section 5(c) for charges associated with the facility (i.e., hospital or other outpatient facility, etc.).
PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
You should be aware that some Non-preferred (non-PPO) professional providers may provide services in Preferred (PPO) facilities.
Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drug when obtained from a covered provider other than a pharmacy under the pharmacy benefit. This benefit limitation does not apply if you have primary Medicare Part B coverage or are enrolled in the FEP Medicare Prescription Drug Program. See Section 5(f) for information about Tier 4 and Tier 5 specialty drug fills from Preferred providers and Preferred pharmacies. Medications restricted under this benefit are available on our Specialty Drug List. Visit www.fepblue.org/specialtypharmacy or call us at 888-346-3731.
Under Standard Option,
- The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment).
- We provide benefits at 85% of the Plan allowance for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, neonatologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician’s office). You may be responsible for any difference between our payment and the billed amount. See Section 4, NSA, for information on when you are not responsible for this difference.
Under Basic Option,
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits. See below and Section 3 for the exceptions to this requirement.
- We provide benefits at Preferred benefit levels for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, neonatologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician’s office). You may be responsible for any difference between our payment and the billed amount. See Section 4, NSA, for information on when you are not responsible for this difference.