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 39
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 39
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefit Description
Diagnostic and Treatment Services
Outpatient professional services of physicians and other healthcare professionals:
Note: Please refer to Section 5(c) for our coverage of these services when billed for by a facility, such as the outpatient department of a hospital.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit (no deductible)
Preferred specialist: $40 copayment per visit (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
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $45 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.
Participating/Non-participating: You pay all charges
Benefit Description
Diagnostic and Treatment Services
Outpatient professional services of physicians and other healthcare professionals:
- Consultations
- Genetic counseling
- Second surgical opinions
- Clinic visits
- Office visits
- Home visits
- Initial examination of a newborn needing definitive treatment when covered under a Self Plus One or Self and Family enrollment
- Pharmacotherapy (medication management) (See Section 5(f) for prescription drug coverage)
- Phone consultations and online medical evaluation and management services (telemedicine)
Note: Please refer to Section 5(c) for our coverage of these services when billed for by a facility, such as the outpatient department of a hospital.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment per visit (no deductible)
Preferred specialist: $40 copayment per visit (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
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $45 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.
Participating/Non-participating: You pay all charges
Benefit Description
Telehealth professional services for:
Note: Refer to Section 5(h), Wellness and Other Special Features, for information on telehealth services and how to access a provider.
Note: Copayments are waived for members with Medicare Part B primary.
Standard Option - You Pay
Preferred Telehealth Provider: Nothing (no deductible)
Participating/Non-participating: You pay all charges
Basic Option - You Pay
Preferred Telehealth Provider: Nothing
Participating/Non-participating: You pay all charges
Telehealth professional services for:
- Minor acute conditions
- Dermatology care
Note: Refer to Section 5(h), Wellness and Other Special Features, for information on telehealth services and how to access a provider.
Note: Copayments are waived for members with Medicare Part B primary.
Standard Option - You Pay
Preferred Telehealth Provider: Nothing (no deductible)
Participating/Non-participating: You pay all charges
Basic Option - You Pay
Preferred Telehealth Provider: Nothing
Participating/Non-participating: You pay all charges
Benefit Description
Inpatient professional services:
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: Nothing
Participating/Non-participating: You pay all charges
Inpatient professional services:
- During a covered hospital stay
- Services for nonsurgical procedures when ordered, provided, and billed by a physician during a covered inpatient hospital admission
- Medical care by the attending physician (the physician who is primarily responsible for your care when you are hospitalized) on days we pay hospital benefits
Note: A consulting physician employed by the hospital is not the attending physician.
- Consultations when requested by the attending physician
- Concurrent care – hospital inpatient care by a physician other than the attending physician for a condition not related to your primary diagnosis, or because the medical complexity of your condition requires this additional medical 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
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Diagnostic and Treatment Services - continued on next page