2023 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
Treatment Therapies
Section 5. Benefits
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Treatment Therapies
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
Treatment Therapies
Outpatient treatment therapies:
Note: See Section 5(c) for our payment levels for treatment therapies billed for by the outpatient department of a hospital.
Note: See page 60 for our coverage of osteopathic and chiropractic manipulative treatment.
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 primary care provider or other healthcare professional: $30 copayment per visit
Preferred specialist: $40 copayment per visit
Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Participating/Non-participating: You pay all charges
Benefit Description
Treatment Therapies
Outpatient treatment therapies:
- Chemotherapy and radiation therapy
Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also, Other services under You need prior Plan approval for certain services in Section 3 (pages 21-24).
Note: You must get prior approval for certain radiation therapy treatments. Please refer to page 22 for more information.
- Renal dialysis – Hemodialysis and peritoneal dialysis
- Intravenous (IV)/infusion therapy – Home IV or infusion therapy
Note: Home nursing visits associated with Home IV/infusion therapy are covered as shown under Home Health Services on page 59.
- Outpatient cardiac rehabilitation
- Pulmonary rehabilitation therapy
- Applied behavior analysis (ABA) for the treatment of an autism spectrum disorder (see prior approval requirements on page 22)
Note: See Section 5(c) for our payment levels for treatment therapies billed for by the outpatient department of a hospital.
Note: See page 60 for our coverage of osteopathic and chiropractic manipulative treatment.
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 primary care provider or other healthcare professional: $30 copayment per visit
Preferred specialist: $40 copayment per visit
Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Participating/Non-participating: You pay all charges
Benefit Description
Note: See above for your costs for intravenous (IV)/infusion therapy - Home IV or infusion therapy.
Standard Option - You Pay
Preferred: 10% of the Plan allowance (deductible applies)
Participating: 15% of the Plan allowance (deductible applies)
Non-participating: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and billed amount
Basic Option - You Pay
Preferred: 15% of the Plan allowance
Participating or Non-participating: You pay all charges
- Auto-immune infusion medications: Remicade, Renflexis and Inflectra
Note: See above for your costs for intravenous (IV)/infusion therapy - Home IV or infusion therapy.
Standard Option - You Pay
Preferred: 10% of the Plan allowance (deductible applies)
Participating: 15% of the Plan allowance (deductible applies)
Non-participating: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and billed amount
Basic Option - You Pay
Preferred: 15% of the Plan allowance
Participating or Non-participating: You pay all charges
Benefit Description
Inpatient treatment therapies:
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: Nothing
Participating/Non-participating: You pay all charges
Inpatient treatment therapies:
- Chemotherapy and radiation therapy
Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also Other services under You need prior Plan approval for certain services in Section 3 (pages 21-24).
- Renal dialysis – Hemodialysis and peritoneal dialysis
- Pharmacotherapy (medication management) (See Section 5(c) for our coverage of drugs administered in connection with these treatment therapies.)
- Applied behavior analysis (ABA) for the treatment of an autism spectrum disorder (see prior approval requirements on page 22)
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: Nothing
Participating/Non-participating: You pay all charges