2025 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 53
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 53
Benefit Description
Treatment Therapies (cont.)
Inpatient treatment therapies:
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: Nothing
Participating/Non-participating: You pay all charges
Treatment Therapies (cont.)
Inpatient treatment therapies:
- Chemotherapy and radiation therapy
Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also Other services under You need prior Plan approval for certain services in Section 3.
- Renal dialysis – Hemodialysis and peritoneal dialysis
- Pharmacotherapy (medication management) (See Section 5(c) for our coverage of drugs administered in connection with these treatment therapies.)
- Applied behavior analysis (ABA) for the treatment of an autism spectrum disorder (see prior approval requirements in Section 3)
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: Nothing
Participating/Non-participating: You pay all charges
Benefit Description
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit (no deductible)
Preferred specialist: $40 copayment per visit (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
Note: Benefits are limited to 75 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $50 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.
Note: Benefits are limited to 50 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
Participating/Non-participating: You pay all charges
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy
- Physical therapy, occupational therapy, and speech therapy
- Cognitive rehabilitation therapy
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit (no deductible)
Preferred specialist: $40 copayment per visit (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
Note: Benefits are limited to 75 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $50 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.
Note: Benefits are limited to 50 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.
Participating/Non-participating: You pay all charges
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy - continued on next page