2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 86
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 86
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage.
Standard Option - You Pay
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Basic Option - You Pay
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Outpatient Hospital or Ambulatory Surgical Center (cont.)
Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage.
Standard Option - You Pay
See previous page
Basic Option - You Pay
See previous page
Benefit Description
Blue Distinction® Specialty Care
We provide enhanced benefits for covered inpatient facility services related to the surgical procedures listed below, when the surgery is performed at a facility designated as a Blue Distinction Center for Knee and Hip Replacement, Blue Distinction Center for Spine Surgery, or Blue Distinction Center for Comprehensive Bariatric Surgery.
Note: You must precertify your hospital stay and verify your facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to your admission at the customer service phone number listed on the back of your ID card for assistance.
Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).
Note: These benefit levels do not apply to inpatient facility care related to other services or procedures, or to outpatient facility care, even if the services are performed at a Blue Distinction Center. See pages 78-80 for regular inpatient hospital benefits and pages 81-85 for outpatient facility benefit levels.
Note: See pages 18-19 for more information about Blue Distinction Centers.
Standard Option - You Pay
Blue Distinction Center: $150 per admission copayment for unlimited days (no deductible)
Basic Option - You Pay
Blue Distinction Center: $100 per day copayment up to $500 per admission for unlimited days
Blue Distinction® Specialty Care
We provide enhanced benefits for covered inpatient facility services related to the surgical procedures listed below, when the surgery is performed at a facility designated as a Blue Distinction Center for Knee and Hip Replacement, Blue Distinction Center for Spine Surgery, or Blue Distinction Center for Comprehensive Bariatric Surgery.
- Bariatric surgeries covered are:
- Roux-en-Y gastric bypass
- Laparoscopic adjustable gastric banding
- Sleeve gastrectomy
- Biliopancreatic bypass with duodenal switch
- Roux-en-Y gastric bypass
- Total hip replacement or revision
- Total knee replacement or revision
- Spine surgery, limited to:
- Cervical discectomy
- Thoracic discectomy
- Laminectomy
- Laminoplasty
- Spinal fusion
- Cervical discectomy
Note: You must precertify your hospital stay and verify your facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to your admission at the customer service phone number listed on the back of your ID card for assistance.
Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).
Note: These benefit levels do not apply to inpatient facility care related to other services or procedures, or to outpatient facility care, even if the services are performed at a Blue Distinction Center. See pages 78-80 for regular inpatient hospital benefits and pages 81-85 for outpatient facility benefit levels.
Note: See pages 18-19 for more information about Blue Distinction Centers.
Standard Option - You Pay
Blue Distinction Center: $150 per admission copayment for unlimited days (no deductible)
Basic Option - You Pay
Blue Distinction Center: $100 per day copayment up to $500 per admission for unlimited days
Blue Distinction® Specialty Care - continued on next page