2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 83
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 83
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Note: For outpatient observation services related to maternity, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Continued from previous page:
Non-member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
See previous page
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Note: For outpatient observation services related to maternity, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Continued from previous page:
Non-member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
See previous page
Benefit Description
Outpatient diagnostic testing and treatment services performed and billed by a facility, limited to:
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $200 copayment per day per facility
Member facilities: $200 copayment per day per facility
Non-member facilities: $200 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Outpatient diagnostic testing and treatment services performed and billed by a facility, limited to:
- Angiographies
- Bone density tests
- CT scans/MRIs/PET scans
- Nuclear medicine
- Facility-based sleep studies (prior approval is required)
- Genetic testing
Note: We cover specialized diagnostic genetic testing billed for by a facility, such as the outpatient department of a hospital, as shown here. See page 41 for coverage criteria and limitations.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $200 copayment per day per facility
Member facilities: $200 copayment per day per facility
Non-member facilities: $200 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Benefit Description
Outpatient diagnostic testing services performed and billed by a facility, such as:
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $40 copayment per day per facility
Member facilities: $40 copayment per day per facility
Non-member facilities: $40 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Outpatient diagnostic testing services performed and billed by a facility, such as:
- Cardiovascular monitoring
- EEGs
- Home-based/unattended sleep studies
- Ultrasounds
- Neurological testing
- X-rays (including set-up of portable X-ray equipment)
Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
Standard Option - You Pay
Preferred facilities: 15% of the Plan allowance (deductible applies)
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.
Basic Option - You Pay
Preferred facilities: $40 copayment per day per facility
Member facilities: $40 copayment per day per facility
Non-member facilities: $40 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page 152 for more information about “agents.”)
Outpatient Hospital or Ambulatory Surgical Center - continued on next page