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 45
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 45
Benefit Description
Preventive Care, Adult (cont.)
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance and deductible.
Standard Option - You Pay
See page 42
Basic Option - You Pay
See page 42
Preventive Care, Adult (cont.)
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance and deductible.
Standard Option - You Pay
See page 42
Basic Option - You Pay
See page 42
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Genetic testing related to family history of cancer or other disease, except as described on page 44
Note: See page 41 for our coverage of medically necessary diagnostic genetic testing.
- Genetic panels when some or all of the tests included in the panel are not covered, are experimental or investigational, or are not medically necessary
- Self-administered health risk assessments (other than the Blue Health Assessment)
- Screening services requested solely by the member, such as commercially advertised heart scans, body scans, and tests performed in mobile traveling vans
- Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
- Immunizations, boosters, and medications for travel or work-related exposure. Medical benefits may be available for these services.
- Phone consultations and online medical evaluation and management services (telemedicine) for preventive services, except as noted on page 42 for nutritional counseling.
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:
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
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges (except as noted below)
Note: For services billed by Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.
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.
Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:
- Well-child visits, examinations, and other preventive services described in the Bright Future Guidelines as provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Future Guidelines go to https://brightfutures.aap.org
- Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to specific age ranges, frequencies, and/or other patient-specific indications, including gender.
- To build your personalized list of preventive services go to https://health.gov/myhealthfinder
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
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges (except as noted below)
Note: For services billed by Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.
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.
Preventive Care, Child - continued on next page