2025 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 81
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 81
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient treatment services performed and billed by a facility, limited to:
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: $35 copayment per day per facility
Note: You may be responsible for paying a higher 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.
Member/Non-member facilities: You pay all charges
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient treatment services performed and billed by a facility, limited to:
- Cardiac rehabilitation
- Pulmonary rehabilitation
- Applied behavior analysis (ABA) for an autism spectrum disorder (see prior approval requirements in Section 3)
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: $35 copayment per day per facility
Note: You may be responsible for paying a higher 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.
Member/Non-member facilities: You pay all charges
Benefit Description
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.
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.
Benefit Description
Outpatient adult preventive care performed and billed by a facility, limited to:
Note: See Section 5(a) 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 Section 5(a) 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 in Section 5(a)
- Cancer screenings listed in Section 5(a) and ultrasound screening for abdominal aortic aneurysm
Note: See Section 5(a) 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 Section 5(a) 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 Hospital or Ambulatory Surgical Center - continued on next page