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 46
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 46
Benefit Description
Preventive Care, Child (cont.)
Note: Preventive care benefits for each of the services listed below are limited to one per calendar year.
Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.
Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
Note: See page 112 for our payment levels for medications to promote better health as recommended under the Affordable Care Act.
Standard Option - You Pay
Continued from previous page:
Note: We waive the deductible and coinsurance amount 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.
Basic Option - You Pay
Continued from previous page:
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.
Preventive Care, Child (cont.)
Note: Preventive care benefits for each of the services listed below are limited to one per calendar year.
- Screening for hepatitis B for children age 13 and over
- Screening for chlamydial infection
- Screening for gonorrhea infection
- Cervical cancer screening tests
- Pap tests of the cervix
- Human papillomavirus (HPV) tests of the cervix
Note: See page 44 for covered BRCA testing.
- Pap tests of the cervix
- Screening for human immunodeficiency virus (HIV) infection
- Screening for syphilis infection
- Screening for latent tuberculosis infection for children ages 18 through 21
- Nutritional counseling
Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.
Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
Note: See page 112 for our payment levels for medications to promote better health as recommended under the Affordable Care Act.
Standard Option - You Pay
Continued from previous page:
Note: We waive the deductible and coinsurance amount 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.
Basic Option - You Pay
Continued from previous page:
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.
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- 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.
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Preventive Care, Child - continued on next page