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 43
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 43
Benefit Description
Preventive Care, Adult (cont.)
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 discussed under Preventive Care, Adult, do not apply to individuals aged 21 and younger. (See benefits under Preventive Care, Child, this section.)
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.
Preventive Care, Adult (cont.)
- 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 discussed under Preventive Care, Adult, do not apply to individuals aged 21 and younger. (See benefits under Preventive Care, Child, this section.)
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.
Preventive Care, Adult - continued on next page