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
Alternative Treatments
Section 5. Benefits
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Alternative Treatments
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
Alternative Treatments
Acupuncture
Note: Acupuncture must be performed and billed by a healthcare provider who is licensed or certified to perform acupuncture by the state where the services are provided, and who is acting within the scope of that license or certification. See page 17 for more information.
Note: When billed by a facility such as the outpatient department of a hospital, you are limited to the number of visits per calendar year listed on this page. See Section 5(c) for your cost-share.
Note: See page 77 for our coverage of acupuncture when provided as anesthesia for covered surgery.
Note: See page 47 for our coverage of acupuncture when provided as anesthesia for covered maternity care.
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
Note: Benefits for acupuncture are limited to 24 visits per calendar year.
Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit
Preferred specialist: $40 copayment per visit
Note: Benefits for acupuncture are limited to 12 visits per calendar year.
Note: You pay 30% of the Plan allowance for drugs and supplies.
Participating/Non-participating: You pay all charges
Benefit Description
Alternative Treatments
Acupuncture
Note: Acupuncture must be performed and billed by a healthcare provider who is licensed or certified to perform acupuncture by the state where the services are provided, and who is acting within the scope of that license or certification. See page 17 for more information.
Note: When billed by a facility such as the outpatient department of a hospital, you are limited to the number of visits per calendar year listed on this page. See Section 5(c) for your cost-share.
Note: See page 77 for our coverage of acupuncture when provided as anesthesia for covered surgery.
Note: See page 47 for our coverage of acupuncture when provided as anesthesia for covered maternity care.
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
Note: Benefits for acupuncture are limited to 24 visits per calendar year.
Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit
Preferred specialist: $40 copayment per visit
Note: Benefits for acupuncture are limited to 12 visits per calendar year.
Note: You pay 30% of the Plan allowance for drugs and supplies.
Participating/Non-participating: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Biofeedback
- Self-care or self-help training
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges