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 44
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 44
Benefit Description
Preventive Care, Adult (cont.)
Note: We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year. If you receive both preventive and diagnostic services from your Provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
Note: See page 112 for our payment levels for medications to promote better health as recommended under the Affordable Care Act.
Note: See page 113 for our payment levels for certain bowel preparation medications, and antiretroviral medications for the prevention of HIV.
Note: Unless otherwise noted, the benefits listed above and on pages 42-43 do not apply to children up to age 22. (See benefits under Preventive Care, Child, this Section.)
Standard Option - You Pay
See previous page
Basic Option - You Pay
See previous page
Preventive Care, Adult (cont.)
Note: We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year. If you receive both preventive and diagnostic services from your Provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
Note: See page 112 for our payment levels for medications to promote better health as recommended under the Affordable Care Act.
Note: See page 113 for our payment levels for certain bowel preparation medications, and antiretroviral medications for the prevention of HIV.
Note: Unless otherwise noted, the benefits listed above and on pages 42-43 do not apply to children up to age 22. (See benefits under Preventive Care, Child, this Section.)
Standard Option - You Pay
See previous page
Basic Option - You Pay
See previous page
Benefit Description
Hereditary Breast and Ovarian Cancer Screening
Benefits are available for screening members, age 18 and over (including children ages 18 – 21) limited to one of each type of test per lifetime, to evaluate the risk for developing certain types of hereditary breast or ovarian cancer related to mutations in BRCA1 and BRCA2 genes:
Note: See page 63 for the benefits available for the surgical removal of breast, ovaries, or prostate when screening reveals a BRCA mutation: preventive care benefits are not available.
Standard Option - You Pay
See page 42
Basic Option - You Pay
See page 42
Hereditary Breast and Ovarian Cancer Screening
Benefits are available for screening members, age 18 and over (including children ages 18 – 21) limited to one of each type of test per lifetime, to evaluate the risk for developing certain types of hereditary breast or ovarian cancer related to mutations in BRCA1 and BRCA2 genes:
- Genetic counseling and evaluation for members whose personal and/or family history is associated with an increased risk for harmful mutations in BRCA1 and BRCA2 genes.
- BRCA testing for members whose personal and/or family history is associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes.
Note: You must receive genetic counseling and evaluation services and obtain prior approval before you receive preventive BRCA testing. Preventive care benefits will not be provided for BRCA testing unless you receive genetic counseling and evaluation prior to the test, and scientifically valid screening measures are used for the evaluation, and the results support BRCA testing. See page 22 for information about prior approval and additional BRCA coverage or call the phone number on the back of your ID card for additional policy information.
Note: See page 63 for the benefits available for the surgical removal of breast, ovaries, or prostate when screening reveals a BRCA mutation: preventive care benefits are not available.
Standard Option - You Pay
See page 42
Basic Option - You Pay
See page 42
Preventive Care, Adult - continued on next page