2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 4. Your Costs for Covered Services
Page 31
Section 4. Your Costs for Covered Services
Page 31
EXAMPLE
Preferred Physician Standard Option
Physician’s charge: $250
Our allowance: We set it at: 100
We pay: 85% of our allowance: 85
You owe - Coinsurance: 15% of our allowance: 15
You owe - Copayment: Not applicable
+ Difference up to charge? No: 0
TOTAL YOU PAY: $15
Participating Physician Standard Option
Physician’s charge: $250
Our allowance: We set it at: 100
We pay: 65% of our allowance: 65
You owe - Coinsurance: 35% of our allowance: 35
You owe - Copayment: Not applicable
+ Difference up to charge? No: 0
TOTAL YOU PAY: $35
Non-participating Physician Standard Option
Physician’s charge: $250
Our allowance: We set it at: 100
We pay: 65% of our allowance: 65
You owe - Coinsurance: 35% of our allowance: 35
You owe - Copayment: Not applicable
+ Difference up to charge? Yes: 150
TOTAL YOU PAY: $185
Note: If you had not met any of your Standard Option deductible in the above example, only our allowance ($100), which you would pay in full, would count toward your deductible.
You should also see Important Notice About Surprise Billing – Know Your Rights in this section that describes your protections against surprise billing under the No Surprises Act.
In the following example, we compare how much you have to pay out-of-pocket for services billed by a Preferred, Member, and Non-member ambulatory surgical facility for facility care associated with an outpatient surgical procedure. The table uses an example of services for which the ambulatory surgical facility charges $5,000. The Plan allowance is $2,900 when the services are provided at a Preferred or Member facility, and the Plan allowance is $2,500 when the services are provided at a Non-member facility.
EXAMPLE
Preferred Ambulatory Surgical Facility Standard Option
Facility’s charge: $5,000
Our allowance: We set it at: 2,900
We pay: 85% of our allowance: 2,465
You owe - Coinsurance: 15% of our allowance: 435
You owe - Copayment: Not applicable
+ Difference up to charge? No: 0
TOTAL YOU PAY: $435
Member Ambulatory Surgical Facility Standard Option
Facility’s charge: $5,000
Our allowance: We set it at: 2,900
We pay: 65% of our allowance: 1,885
You owe - Coinsurance: 35% of our allowance: 1,015
You owe - Copayment: Not applicable
+ Difference up to charge? No: 0
TOTAL YOU PAY: $1,015
Preferred Physician Standard Option
Physician’s charge: $250
Our allowance: We set it at: 100
We pay: 85% of our allowance: 85
You owe - Coinsurance: 15% of our allowance: 15
You owe - Copayment: Not applicable
+ Difference up to charge? No: 0
TOTAL YOU PAY: $15
Participating Physician Standard Option
Physician’s charge: $250
Our allowance: We set it at: 100
We pay: 65% of our allowance: 65
You owe - Coinsurance: 35% of our allowance: 35
You owe - Copayment: Not applicable
+ Difference up to charge? No: 0
TOTAL YOU PAY: $35
Non-participating Physician Standard Option
Physician’s charge: $250
Our allowance: We set it at: 100
We pay: 65% of our allowance: 65
You owe - Coinsurance: 35% of our allowance: 35
You owe - Copayment: Not applicable
+ Difference up to charge? Yes: 150
TOTAL YOU PAY: $185
Note: If you had not met any of your Standard Option deductible in the above example, only our allowance ($100), which you would pay in full, would count toward your deductible.
You should also see Important Notice About Surprise Billing – Know Your Rights in this section that describes your protections against surprise billing under the No Surprises Act.
In the following example, we compare how much you have to pay out-of-pocket for services billed by a Preferred, Member, and Non-member ambulatory surgical facility for facility care associated with an outpatient surgical procedure. The table uses an example of services for which the ambulatory surgical facility charges $5,000. The Plan allowance is $2,900 when the services are provided at a Preferred or Member facility, and the Plan allowance is $2,500 when the services are provided at a Non-member facility.
EXAMPLE
Preferred Ambulatory Surgical Facility Standard Option
Facility’s charge: $5,000
Our allowance: We set it at: 2,900
We pay: 85% of our allowance: 2,465
You owe - Coinsurance: 15% of our allowance: 435
You owe - Copayment: Not applicable
+ Difference up to charge? No: 0
TOTAL YOU PAY: $435
Member Ambulatory Surgical Facility Standard Option
Facility’s charge: $5,000
Our allowance: We set it at: 2,900
We pay: 65% of our allowance: 1,885
You owe - Coinsurance: 35% of our allowance: 1,015
You owe - Copayment: Not applicable
+ Difference up to charge? No: 0
TOTAL YOU PAY: $1,015