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 42
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 42
Benefit Description
Lab, X-ray and Other Diagnostic Tests (cont.)
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Basic Option - You Pay
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Lab, X-ray and Other Diagnostic Tests (cont.)
Note: You must obtain prior approval for BRCA testing (see page 22). Diagnostic BRCA testing, including testing for large genomic rearrangements in the BRCA1 and BRCA2 genes: Benefits are available for members with a cancer diagnosis when the requirements in the note above are met, and the member does not meet criteria for Preventive BRCA testing. Benefits are limited to one test of each type per lifetime whether covered as a diagnostic test or paid under Preventive Care benefits (see page 44).
Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.
Standard Option - You PayNote: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.
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Basic Option - You Pay
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Benefit Description
Preventive Care, Adult
Benefits are provided for preventive care services for adults age 22 and over.
Covered services include:
Preventive care benefits for each of the services listed below are limited to one per calendar year.
Standard Option - You Pay
Preferred: Nothing (no deductible)
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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.
Note: We waive your 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
Preferred: Nothing
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Note: Benefits are not available for visits/exams for preventive care, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Preventive Care, Adult
Benefits are provided for preventive care services for adults age 22 and over.
Covered services include:
- Counseling on prevention and reducing health risks
- Nutritional counseling 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.
- Visits/exams for preventive care Note: See the definition of Preventive Care, Adult, on page 158 for included health screening services.
Preventive care benefits for each of the services listed below are limited to one per calendar year.
- Administration and interpretation of a Health Risk Assessment (HRA) questionnaire (see Definitions.)
Note: As a member of the Service Benefit Plan, you have access to the Blue Cross and Blue Shield HRA, called the “Blue Health Assessment” questionnaire. See Section 5(h) for complete information.
- Basic or comprehensive metabolic panel test
- CBC
- Cervical cancer screening tests
- Human papillomavirus (HPV) tests of cervix
- Pap tests of the cervix
- Human papillomavirus (HPV) tests of cervix
- Colorectal cancer tests, including:
- Colonoscopy, with or without biopsy (see page 63 for our payment levels for diagnostic colonoscopies)
- CT colonography
- DNA analysis of stool samples
- Double contrast barium enema
- Fecal occult blood test
- Sigmoidoscopy
- Colonoscopy, with or without biopsy (see page 63 for our payment levels for diagnostic colonoscopies)
Standard Option - You Pay
Preferred: Nothing (no deductible)
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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.
Note: We waive your 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
Preferred: Nothing
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Note: Benefits are not available for visits/exams for preventive care, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Preventive Care, Adult - continued on next page