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 41
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 41
Benefit Description
Lab, X-ray and Other Diagnostic Tests (cont.)
Standard Option - You Pay
Continued from previous page:
Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.
Basic Option - You Pay
Continued from previous page:
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, in addition to the Preferred coinsurance listed on the previous page.
Lab, X-ray and Other Diagnostic Tests (cont.)
Standard Option - You Pay
Continued from previous page:
Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.
Basic Option - You Pay
Continued from previous page:
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, in addition to the Preferred coinsurance listed on the previous page.
Benefit Description
Diagnostic tests including but not limited to:
Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.
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
Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.
Basic Option - You Pay
Preferred: $40 copayment
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 (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 in addition to the Preferred copayment listed above.
Diagnostic tests including but not limited to:
- Cardiovascular monitoring
- EEGs
- Home-based/unattended sleep studies
- Neurological testing
- Ultrasounds
- X-rays (including set-up of portable X-ray equipment)
Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.
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
Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.
Basic Option - You Pay
Preferred: $40 copayment
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 (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 in addition to the Preferred copayment listed above.
Benefit Description
Diagnostic tests limited to:
Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient’s existing medical condition. Benefits are not provided for genetic panels when some or all of the tests included in the panel are not covered, are experimental or investigational, or are not medically necessary.
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
Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.
Basic Option - You Pay
Preferred: $100 copayment
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 (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 in addition to the Preferred copayment listed above.
Diagnostic tests limited to:
- Bone density tests
- CT scans/MRIs/PET scans
- Angiographies
- Nuclear medicine
- Facility-based sleep studies (prior approval required)
- Genetic testing
Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient’s existing medical condition. Benefits are not provided for genetic panels when some or all of the tests included in the panel are not covered, are experimental or investigational, or are not medically necessary.
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
Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.
Basic Option - You Pay
Preferred: $100 copayment
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 (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 in addition to the Preferred copayment listed above.
Lab, X-ray and Other Diagnostic Tests - continued on next page