2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5. Benefits
Section 5. Benefits
See towards the end of the brochure for a benefits summary of each option. Make sure that you review the benefits that are available under the option in which you are enrolled.
Section 5. Standard and Basic Option Overview - 37
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals - 38
Non-PSHB Benefits Available to Plan Members - 135
Section 5. Standard and Basic Option Overview - 37
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals - 38
Diagnostic and Treatment Services - 39
Lab, X-ray and Other Diagnostic Tests - 40
Preventive Care, Adult - 42
Preventive Care, Child - 45
Maternity Care - 47
Family Planning - 49
Reproductive Services - 50
Allergy Care - 51
Treatment Therapies - 52
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy - 53
Hearing Services (Testing, Treatment, and Supplies) - 54
Vision Services (Testing, Treatment, and Supplies) - 54
Foot Care - 56
Orthopedic and Prosthetic Devices - 56
Durable Medical Equipment (DME) - 57
Medical Supplies - 58
Home Health Services - 59
Manipulative Treatment - 60
Alternative Treatments - 60
Educational Classes and Programs - 61
Lab, X-ray and Other Diagnostic Tests - 40
Preventive Care, Adult - 42
Preventive Care, Child - 45
Maternity Care - 47
Family Planning - 49
Reproductive Services - 50
Allergy Care - 51
Treatment Therapies - 52
Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy - 53
Hearing Services (Testing, Treatment, and Supplies) - 54
Vision Services (Testing, Treatment, and Supplies) - 54
Foot Care - 56
Orthopedic and Prosthetic Devices - 56
Durable Medical Equipment (DME) - 57
Medical Supplies - 58
Home Health Services - 59
Manipulative Treatment - 60
Alternative Treatments - 60
Educational Classes and Programs - 61
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals - 62
Surgical Procedures - 63
Reconstructive Surgery - 64
Oral and Maxillofacial Surgery - 67
Organ/Tissue Transplants - 68
Anesthesia - 73
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services - 75 Oral and Maxillofacial Surgery - 67
Organ/Tissue Transplants - 68
Anesthesia - 73
Inpatient Hospital - 76
Outpatient Hospital or Ambulatory Surgical Center - 78
Blue Distinction® Specialty Care - 82
Residential Treatment Center - 83
Extended Care Benefits/Skilled Nursing Care Facility Benefits - 84
Hospice Care - 85
Ambulance - 88
Section 5(d). Emergency Services/Accidents - 90 Section 5(e). Mental Health and Substance Use Disorder Benefits - 94 Outpatient Hospital or Ambulatory Surgical Center - 78
Blue Distinction® Specialty Care - 82
Residential Treatment Center - 83
Extended Care Benefits/Skilled Nursing Care Facility Benefits - 84
Hospice Care - 85
Ambulance - 88
Professional Services - 95
Inpatient Hospital or Other Covered Facility - 96
Residential Treatment Center - 96
Outpatient Hospital or Other Covered Facility - 97
Not Covered (Inpatient or Outpatient) - 97
Section 5(f). Prescription Drug Benefits - 99 Inpatient Hospital or Other Covered Facility - 96
Residential Treatment Center - 96
Outpatient Hospital or Other Covered Facility - 97
Not Covered (Inpatient or Outpatient) - 97
Covered Medications and Supplies - 104
Section 5(f)(a). FEP Medicare Prescription Drug Plan - 109 Covered Medications and Supplies - 113
Section 5(g). Dental Benefits - 123 Section 5(h). Wellness and Other Special Features - 127 Health Tools - 127
Services for the Deaf and Hearing Impaired - 127
Web Accessibility for the Visually Impaired - 127
Travel Benefit/Services Overseas - 127
Healthy Families - 127
Diabetes Management Program - 127
Blue Health Assessment - 127
Hypertension Management Program - 128
Pregnancy Care Incentive Program - 128
Annual Incentive Limitation - 129
Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B - 129
MyBlue® Customer eService - 129
National Doctor & Hospital Finder - 129
Care Management Programs - 129
Flexible Benefits Option - 130
Telehealth Services - 131
The fepblue Mobile Application - 131
Section 5(i). Services, Drugs, and Supplies Provided Overseas - 132 Services for the Deaf and Hearing Impaired - 127
Web Accessibility for the Visually Impaired - 127
Travel Benefit/Services Overseas - 127
Healthy Families - 127
Diabetes Management Program - 127
Blue Health Assessment - 127
Hypertension Management Program - 128
Pregnancy Care Incentive Program - 128
Annual Incentive Limitation - 129
Reimbursement Account for Basic Option Members Enrolled in Medicare Part A and Part B - 129
MyBlue® Customer eService - 129
National Doctor & Hospital Finder - 129
Care Management Programs - 129
Flexible Benefits Option - 130
Telehealth Services - 131
The fepblue Mobile Application - 131
Non-PSHB Benefits Available to Plan Members - 135