2023 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 56
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 56
Benefit Description
Foot Care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
Note: See Orthopedic and Prosthetic Devices for information on podiatric shoe inserts.
Note: See Section 5(b) for our coverage for surgical procedures.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $25 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies)
Preferred specialist: $35 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (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
Foot Care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
Note: See Orthopedic and Prosthetic Devices for information on podiatric shoe inserts.
Note: See Section 5(b) for our coverage for surgical procedures.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $25 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies)
Preferred specialist: $35 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (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
Not covered: Routine foot care, such as cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered: Routine foot care, such as cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Orthopedic and Prosthetic Devices
Orthopedic braces and prosthetic appliances such as:
Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.
We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b).
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
Orthopedic and Prosthetic Devices
Orthopedic braces and prosthetic appliances such as:
- Artificial limbs and eyes
- Functional foot orthotics when prescribed by a physician
- Rigid devices attached to the foot or a brace, or placed in a shoe
- Replacement, repair, and adjustment of covered devices
- Following a mastectomy, breast prostheses and surgical bras, including necessary replacements
- Surgically implanted penile prostheses limited to treatment of erectile dysfunction or as part of an approved plan for gender affirming surgery
- Surgical implants
Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.
We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b).
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
Orthopedic and Prosthetic Devices - continued on next page