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 45
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 45
Benefit Description
Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:
Note: Preventive care benefits for each of the services listed below are limited to one per calendar year.
Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.
Standard Option - You Pay
Preferred: Nothing (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: 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 the 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
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: We provide benefits 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.
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.
Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:
- Well-child visits, examinations, and other preventive services described in the Bright Future Guidelines as provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Future Guidelines, go to https://brightfutures.aap.org.
- Children's immunizations endorsed by the Centers for Disease Control (CDC) such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations, go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/imz-schedules/index.html.
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to specific age ranges, frequencies, and/or other patient-specific indications, including gender.
- You may also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
- To build your personalized list of preventive services, go to https://health.gov/myhealthfinder.
- Nutritional counseling
Note: Preventive care benefits for each of the services listed below are limited to one per calendar year.
- Screening for hepatitis B for children age 13 and over
- Screening for chlamydial infection
- Screening for gonorrhea infection
- Cervical cancer screening tests
- Pap tests of the cervix
- Human papillomavirus (HPV) tests of the cervix
- Pap tests of the cervix
- Screening for human immunodeficiency virus (HIV) infection
- Screening for syphilis infection
- Screening for latent tuberculosis infection for children ages 18 through 21
Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.
Standard Option - You Pay
Preferred: Nothing (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: 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 the 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
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: We provide benefits 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.
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.
Preventive Care, Child - continued on next page