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 47
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 47
Benefit Description
Preventive Care, Child (cont.)
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Preventive Care, Child (cont.)
Not covered:
- Phone consultations and online medical evaluation and management services (telemedicine) for preventive services, except as noted above for nutritional counseling.
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Maternity Care
Maternity (obstetrical) care including related conditions resulting in childbirth or miscarriage, such as:
Note: See page 42 for our coverage of nutritional counseling.
Note: Benefits for home nursing visits (skilled) related to covered maternity care are subject to the visit limitations described on page 59.
Note: Maternity care benefits are not provided for prescription drugs required during pregnancy, except as recommended under the Affordable Care Act. See page 112 for more information. See Section 5(f) for other prescription drug coverage.
Standard Option - You Pay
Preferred: Nothing (no deductible)
Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use Preferred providers.
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: You may request prior approval and receive specific benefit information in advance for the delivery itself and any other maternity-related surgical procedures to be provided by a Non-participating physician when the charge for that care will be $5,000 or more. Call your Local Plan at the customer service phone number on the back of your ID card to obtain information about your coverage and the Plan allowance for the services.
Basic Option - You Pay
Preferred: Nothing
Note: For Preferred facility care related to maternity, including care at Preferred birthing facilities, your responsibility for covered inpatient services is limited to $250 per admission. For outpatient facility services related to maternity, see the notes on pages 82-85.
Participating/Non-participating: You pay all charges (except as noted below)
Note: For services billed by Non-participating laboratories or radiologists, you are responsible only for any difference between our allowance and the billed amount.
Maternity Care
Maternity (obstetrical) care including related conditions resulting in childbirth or miscarriage, such as:
- Prenatal care (including ultrasound, laboratory, and diagnostic tests)
Note: See Section 5(h) for details about our Pregnancy Care Incentive Program.
- Delivery
- Postpartum care
- Assistant surgeons/surgical assistance if required because of the complexity of the delivery
- Anesthesia (including acupuncture) when requested by the attending physician and performed by a certified registered nurse anesthetist (CRNA) or a physician other than the operating physician (surgeon) or the assistant
- Tocolytic therapy and related services when provided on an inpatient basis during a covered hospital admission or during a covered observation stay
- Breastfeeding education and individual coaching on breastfeeding by healthcare providers such as physicians, physician assistants, midwives, nurse practitioners/clinical specialists, and lactation consultants
Note: See page 48 for our coverage of breast pump kits.
- Mental health treatment for postpartum depression and depression during pregnancy
Note: We provide benefits to cover up to 8 visits per year in full to treat depression associated with pregnancy (i.e., depression during pregnancy, postpartum depression, or both) when you use a Preferred provider. See Section 5(e) for our coverage of mental health visits to Non-preferred providers and benefits for additional mental health services.
Note: See page 42 for our coverage of nutritional counseling.
Note: Benefits for home nursing visits (skilled) related to covered maternity care are subject to the visit limitations described on page 59.
Note: Maternity care benefits are not provided for prescription drugs required during pregnancy, except as recommended under the Affordable Care Act. See page 112 for more information. See Section 5(f) for other prescription drug coverage.
Standard Option - You Pay
Preferred: Nothing (no deductible)
Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use Preferred providers.
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: You may request prior approval and receive specific benefit information in advance for the delivery itself and any other maternity-related surgical procedures to be provided by a Non-participating physician when the charge for that care will be $5,000 or more. Call your Local Plan at the customer service phone number on the back of your ID card to obtain information about your coverage and the Plan allowance for the services.
Basic Option - You Pay
Preferred: Nothing
Note: For Preferred facility care related to maternity, including care at Preferred birthing facilities, your responsibility for covered inpatient services is limited to $250 per admission. For outpatient facility services related to maternity, see the notes on pages 82-85.
Participating/Non-participating: You pay all charges (except as noted below)
Note: For services billed by Non-participating laboratories or radiologists, you are responsible only for any difference between our allowance and the billed amount.
Maternity Care - continued on next page