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 55
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 55
Benefit Description
Vision Services (Testing, Treatment, and Supplies) (cont.)
Note: Benefits are provided for refractions only when the refraction is performed to determine the prescription for the one pair of eyeglasses, replacement lenses, or contact lenses provided per incident as described above and on page 54.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
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
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Vision Services (Testing, Treatment, and Supplies) (cont.)
- For the nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21
Note: Benefits are provided for refractions only when the refraction is performed to determine the prescription for the one pair of eyeglasses, replacement lenses, or contact lenses provided per incident as described above and on page 54.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
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
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Benefit Description
Note: See above and on page 54 for our coverage of eyeglasses, replacement lenses, or contact lenses when prescribed as nonsurgical treatment for amblyopia and strabismus.
Note: See Section 5(b), Surgical procedures, for coverage for surgical treatment of amblyopia and strabismus.
Note: See pages 40-42 in this Section for our payment levels for Lab, X-ray, and other diagnostic tests performed or ordered by your provider. Benefits are not available for refractions except as described above.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $25 copayment (no deductible)
Preferred specialist: $35 copayment (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
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit
Preferred specialist: $40 copayment per visit
Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Participating/Non-participating: You pay all charges
- Eye examinations related to a specific medical condition
- Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21
Note: See above and on page 54 for our coverage of eyeglasses, replacement lenses, or contact lenses when prescribed as nonsurgical treatment for amblyopia and strabismus.
Note: See Section 5(b), Surgical procedures, for coverage for surgical treatment of amblyopia and strabismus.
Note: See pages 40-42 in this Section for our payment levels for Lab, X-ray, and other diagnostic tests performed or ordered by your provider. Benefits are not available for refractions except as described above.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $25 copayment (no deductible)
Preferred specialist: $35 copayment (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
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit
Preferred specialist: $40 copayment per visit
Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Participating/Non-participating: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses, except as described above and on page 54
- Deluxe eyeglass frames or lens features for eyeglasses or contact lenses such as special coating, polarization, UV treatment, etc.
- Multifocal, accommodating, toric, or other premium intraocular lenses (IOLs) including Crystalens, ReStor, and ReZoom
- Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described above
- LASIK, INTACS, radial keratotomy, and other refractive surgical services
- Refractions, including those performed during an eye examination related to a specific medical condition, except as described above
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges