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 61
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 61
Benefit Description
Alternative Treatments (cont.)
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Alternative Treatments (cont.)
Not covered:
- Biofeedback
- Self-care or self-help training
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Educational Classes and Programs
Standard Option - You Pay
Preferred: Nothing (no deductible)
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
Educational Classes and Programs
- Smoking and tobacco cessation treatment
- Counseling for smoking and tobacco cessation
- Smoking and tobacco cessation classes
Note: See Section 5(f) for our coverage of smoking and tobacco cessation drugs.
- Counseling for smoking and tobacco cessation
Standard Option - You Pay
Preferred: Nothing (no deductible)
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
Benefit Description
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
Participating/Non-participating: You pay all charges
- Diabetic education
Note: See pages 40, 42 and 46 for our coverage of nutritional counseling services that are not part of a diabetic education program.
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
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:
- Marital, family, educational, or other counseling or training services, or applied behavior analysis (ABA), when performed as part of an educational class or program
- Premenstrual syndrome (PMS), lactation (except as described on page 47), headache, eating disorder (except as described on pages 40 and 42), and other educational clinics
- Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay
- Services performed or billed by a school or halfway house or a member of its staff
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges