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 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.
Standard Option - You Pay
Continued from previous page:
Note: Many Preferred retail pharmacies participate in our vaccine network. See page 111 for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Basic Option - You Pay
Continued from previous page:
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.
Note: Many Preferred retail pharmacies participate in our vaccine network. See page 111 for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Preventive Care, Adult (cont.)
- Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or triglycerides)
- General health panel
- Prostate cancer test – Prostate Specific Antigen (PSA)
- Screening for chlamydial infection
- Screening for diabetes mellitus
- Screening for gonorrhea infection
- Screening for human immunodeficiency virus (HIV)
- Screening mammograms, including mammography using digital technology
- 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/DTaP) 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
- 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
Standard Option - You Pay
Continued from previous page:
Note: Many Preferred retail pharmacies participate in our vaccine network. See page 111 for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Basic Option - You Pay
Continued from previous page:
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.
Note: Many Preferred retail pharmacies participate in our vaccine network. See page 111 for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Preventive Care, Adult - continued on next page