2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option – 2023
Page 163
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option – 2023
Page 163
Mental health and substance use disorder treatment
PPO: Regular cost-sharing, such as $25 office visit copay; $350 per inpatient admission
Non-PPO: Regular cost-sharing, such as 35%* of our allowance for office visits; $450 per inpatient admission to Member facilities, plus 35% of our allowance
98-102
Prescription drugs
Retail Pharmacy Program:
Dental care
Scheduled allowances for diagnostic and preventive services; regular benefits for dental services required due to accidental injury and covered oral and maxillofacial surgery
123
Wellness and other special features: Health Tools; Blue Health Assessment; MyBlue® Customer eService; Diabetes Management Incentive Program; National Doctor and Hospital Finder; Healthy Families; travel benefit/services overseas; Care Management Programs; and Flexible benefits option
See Section 5(h).
125-129
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
32-33
PPO: Regular cost-sharing, such as $25 office visit copay; $350 per inpatient admission
Non-PPO: Regular cost-sharing, such as 35%* of our allowance for office visits; $450 per inpatient admission to Member facilities, plus 35% of our allowance
98-102
Prescription drugs
Retail Pharmacy Program:
- PPO: $7.50 for each purchase of up to a 30-day supply generic ($5.00 for a 30-day supply if you have Medicare Part B primary)/30% of our allowance Preferred brand-name/50% of our allowance non-preferred brand-name
- Non-PPO: 45% of our allowance (AWP)
- $15 generic ($10 if you have Medicare Part B primary)/$90 Preferred brand-name/$125 non-preferred brand-name per prescription; up to a 90-day supply
- $65 preferred specialty drug for a purchase of up to a 30-day supply; $85 non-preferred specialty drug for a purchase of up to a 30-day supply
Dental care
Scheduled allowances for diagnostic and preventive services; regular benefits for dental services required due to accidental injury and covered oral and maxillofacial surgery
123
Wellness and other special features: Health Tools; Blue Health Assessment; MyBlue® Customer eService; Diabetes Management Incentive Program; National Doctor and Hospital Finder; Healthy Families; travel benefit/services overseas; Care Management Programs; and Flexible benefits option
See Section 5(h).
125-129
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
- Self Only: Nothing after $6,000 (PPO) or $8,000 (PPO/Non-PPO) per contract per year
- Self Plus One: Nothing after $12,000 (PPO) or $16,000 (PPO/Non-PPO) per contract per year
- Self and Family: Nothing after $12,000 (PPO) or $16,000 (PPO/Non-PPO) per contract per year
Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
32-33