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 59
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 59
Benefit Description
Medical Supplies (cont.)
Note: We cover medical supplies at Preferred benefit levels only when you use a Preferred medical supply provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred medical supply providers.
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: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Medical Supplies (cont.)
- Oxygen
Note: When billed by a skilled nursing facility, nursing home, or extended care facility, we pay benefits as shown here for oxygen, according to the contracting status of the facility.
- Blood and blood plasma, except when donated or replaced, and blood plasma expanders
Note: We cover medical supplies at Preferred benefit levels only when you use a Preferred medical supply provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred medical supply providers.
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: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Infant formulas used as a substitute for breastfeeding
- Diabetic supplies, except as described in Section 5(f) or when Medicare Part B is primary, or are enrolled in the FEP Medicare Prescription Drug Program
- Medical foods administered orally, except as described in Section 5(f)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Home Health Services
Home nursing care (skilled) for two hours per day when:
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: Benefits for home nursing care are limited to 50 visits per person, per calendar year.
Note: Visits that you pay for while meeting your calendar year deductible count toward the annual visit limit.
Basic Option - You Pay
Preferred: $35 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 for home nursing care are limited to 25 visits per person, per calendar year.
Participating/Non-participating: You pay all charges
Home Health Services
Home nursing care (skilled) for two hours per day when:
- A registered nurse (R.N.) or licensed practical nurse (L.P.N.) provides the services; and
- A physician orders the care
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: Benefits for home nursing care are limited to 50 visits per person, per calendar year.
Note: Visits that you pay for while meeting your calendar year deductible count toward the annual visit limit.
Basic Option - You Pay
Preferred: $35 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 for home nursing care are limited to 25 visits per person, per calendar year.
Participating/Non-participating: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Nursing care requested by, or for the convenience of, the patient or the patient’s family
- Services primarily for bathing, feeding, exercising, moving the patient, homemaking, giving medication, or acting as a companion or sitter
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Home Health Services - continued on next page