2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2025
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Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option – 2025
Page 166
Mail Service Prescription Drug Program (for primary Medicare Part B members only):
- $20 generic/$100 Preferred brand-name/$125 non-preferred brand-name per prescription; up to a 90-day supply
Dental care
PPO: $35 copayment per evaluation (exam, cleaning, and X-rays); most services limited to 2 per year; sealants for children up to age 16; $35 copayment for associated oral evaluations required due to accidental injury; regular benefits for covered oral and maxillofacial surgery
Non-PPO: You pay all charges
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Wellness and other special features: Health Tools; Blue Health Assessment; MyBlue® Customer eService; National Doctor and Hospital Finder; Healthy Families; travel benefit/services overseas; Care Management Programs; and Flexible benefits option
See Section 5(h).
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Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)
- Self Only: Nothing after $7,500 (PPO) per contract per year
- Self Plus One: Nothing after $15,000 (PPO) per contract per year
- Self and Family: Nothing after $15,000 (PPO) per contract per year; nothing after $7,500 (PPO) per individual per year
Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
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