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 85
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 85
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient diagnostic and treatment services performed and billed by a facility, limited to:
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: 15% of the Plan allowance
Member facilities: 15% of the Plan allowance
Non-member facilities: 15% of the Plan allowance plus any difference between our allowance and the billed amount
Note: You may be responsible for paying a 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 (cont.)
Outpatient diagnostic and treatment services performed and billed by a facility, limited to:
- Laboratory tests and pathology services
- EKGs
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: 15% of the Plan allowance
Member facilities: 15% of the Plan allowance
Non-member facilities: 15% of the Plan allowance plus any difference between our allowance and the billed amount
Note: You may be responsible for paying a 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.”)
Benefit Description
Outpatient adult preventive care performed and billed by a facility, limited to:
Note: See page 44 for our coverage requirements for preventive BRCA testing.
Note: See pages 45-46 for our payment levels for covered preventive care services for children billed for by facilities and performed on an outpatient basis.
Standard Option - You Pay
See page 42 for our payment levels for covered preventive care services for adults
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: Nothing for cancer screenings and ultrasound screening for abdominal aortic aneurysm
Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Outpatient adult preventive care performed and billed by a facility, limited to:
- Visits/exams for preventive care, screening procedures, and routine immunizations described on pages 42-45
- Cancer screenings listed on pages 42-43 and ultrasound screening for abdominal aortic aneurysm
Note: See page 44 for our coverage requirements for preventive BRCA testing.
Note: See pages 45-46 for our payment levels for covered preventive care services for children billed for by facilities and performed on an outpatient basis.
Standard Option - You Pay
See page 42 for our payment levels for covered preventive care services for adults
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: Nothing for cancer screenings and ultrasound screening for abdominal aortic aneurysm
Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Benefit Description
Outpatient drugs, medical devices, and durable medical equipment billed for 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: 30% of the Plan allowance
Note: You may also be responsible for paying a copayment per day per facility for outpatient services. See above and pages 81-84 for specific coverage information.
Member/Non-member facilities: You pay all charges
Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:
- Prescribed drugs
- Orthopedic and prosthetic devices
- Durable medical equipment
- Surgical implants
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: 30% of the Plan allowance
Note: You may also be responsible for paying a copayment per day per facility for outpatient services. See above and pages 81-84 for specific coverage information.
Member/Non-member facilities: You pay all charges