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 79
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 79
Benefit Description
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient diagnostic testing and 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: $250 copayment per day per facility
Member facilities: $250 copayment per day per facility
Non-member facilities: $250 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care.
Outpatient Hospital or Ambulatory Surgical Center (cont.)
Outpatient diagnostic testing and treatment services performed and billed by a facility, limited to:
- Angiographies
- Bone density tests
- CT scans/MRIs/PET scans
- Nuclear medicine
- Facility-based sleep studies (prior approval is required)
- Genetic testing (prior approval is required)
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: $250 copayment per day per facility
Member facilities: $250 copayment per day per facility
Non-member facilities: $250 copayment per day per facility, plus any difference between our allowance and the billed amount
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care.
Benefit Description
Outpatient diagnostic testing services performed and billed by a facility, such as:
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: $40 copayment per day per facility
Member facilities: $40 copayment per day per facility
Non-member facilities: $40 copayment per day per facility, plus any difference between our allowance and the billed amount
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.
Outpatient diagnostic testing services performed and billed by a facility, such as:
- Cardiovascular monitoring
- EEGs
- Home-based/unattended sleep studies
- Ultrasounds
- Neurological testing
- X-rays (including set-up of portable X-ray equipment)
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: $40 copayment per day per facility
Member facilities: $40 copayment per day per facility
Non-member facilities: $40 copayment per day per facility, plus any difference between our allowance and the billed amount
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.
Benefit Description
Outpatient treatment and therapy services performed and billed by a facility, limited to:
Standard Option - You Pay
Preferred facilities: $30 copayment per day per facility (no deductible)
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
Member/Non-member facilities: You pay all charges
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care.
Outpatient treatment and therapy services performed and billed by a facility, limited to:
- Cognitive rehabilitation therapy
- Physical, occupational, and speech therapy
- Standard Option benefits are limited to a combined total of 75 visits per person per calendar year
- Basic Option benefits are limited to a combined total of 50 visits per person per calendar year
- Standard Option benefits are limited to a combined total of 75 visits per person per calendar year
- Manipulative treatment services
- Standard Option benefits are limited to a combined total of 12 visits per person per calendar year
- Basic Option benefits are limited to a combined total of 20 visits per person per calendar year
- Standard Option benefits are limited to a combined total of 12 visits per person per calendar year
Standard Option - You Pay
Preferred facilities: $30 copayment per day per facility (no deductible)
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
Member/Non-member facilities: You pay all charges
Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care.
Outpatient Hospital or Ambulatory Surgical Center - continued on next page