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 45
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 45
Benefit Description
Preventive Care, Child (cont.)
Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
Standard Option - You Pay
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Basic Option - You Pay
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Preventive Care, Child (cont.)
Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
Standard Option - You Pay
See previous page
Basic Option - You Pay
See previous page
Benefit Description
Obesity counseling, screening and referral to intensive nutrition and behavioral weight-loss therapy, or counseling under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:
Note: Benefits are available for anti-obesity medications. See Section 5(f).
Note: See Section 5(b) for information related to benefits for the surgical treatment of severe obesity.
Standard Option - You Pay
Preferred: Nothing (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
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Obesity counseling, screening and referral to intensive nutrition and behavioral weight-loss therapy, or counseling under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:
- Unlimited nutritional counseling including nutritional counseling via the contracted telehealth provider network
- Unlimited visits for counseling on prevention and reducing health risks
- Unlimited visits for individual and group behavioral counseling for obesity
- And, for those children or adolescents with a body mass index (BMI) at or above the 85th percentile, unlimited family-centered programs when medically identified to support obesity prevention and management by an in-network provider.
Note: Benefits are available for anti-obesity medications. See Section 5(f).
Note: See Section 5(b) for information related to benefits for the surgical treatment of severe obesity.
Standard Option - You Pay
Preferred: Nothing (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
Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.
Basic Option - You Pay
Preferred: Nothing
Participating/Non-participating: You pay all charges
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Self-administered health risk assessments (other than the Blue Health Assessment)
- Screening services requested solely by the member, such as commercially advertised heart scans, body scans, and tests performed in mobile traveling vans
- Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel
- Immunizations, boosters, and medications for travel or work-related exposure. Medical benefits may be available for these services.
- Phone consultations and online medical evaluation and management services (telemedicine) for preventive services, except as noted above for nutritional counseling.
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges