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 44
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 44
Benefit Description
Preventive Care, Adult (cont.)
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
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Basic Option - You Pay
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Preventive Care, Adult (cont.)
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
See previous page
Basic Option - You Pay
See previous page
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
Benefit Description
Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:
Standard Option - You Pay
Preferred: Nothing (no deductible)
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.
Basic Option - You Pay
Preferred: Nothing
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: 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.
Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:
- Well-child visits, examinations, and other preventive services described in the Bright Future Guidelines as provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Future Guidelines, go to https://brightfutures.aap.org.
- Immunizations such as Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations, go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html.
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to specific age ranges, frequencies, and/or other patient-specific indications, including gender.
Standard Option - You Pay
Preferred: Nothing (no deductible)
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.
Basic Option - You Pay
Preferred: Nothing
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: 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.
Preventive Care, Child - continued on next page