2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Preventive Care, Child
Section 5. Benefits
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Preventive Care, Child
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
Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:
Note: Preventive care benefits for each of the services listed below are limited to one per calendar year.
Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.
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 (except as noted below)
Note: For services billed by Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.
Note: We provide benefits for services billed by Participating/Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.
Benefit Description
Preventive Care, Child
Benefits are provided for preventive care services for children up to age 22. This includes:
- Well-child visits, examinations, and other preventive services described in the Bright Future Guidelines as provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Future Guidelines go to https://brightfutures.aap.org
- Children's immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/imz-schedules/index.html
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to specific age ranges, frequencies, and/or other patient-specific indications, including gender.
- You may also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
- To build your personalized list of preventive services go to https://health.gov/myhealthfinder
- Nutritional counseling
Note: Preventive care benefits for each of the services listed below are limited to one per calendar year.
- Screening for hepatitis B for children age 13 and over
- Screening for chlamydial infection
- Screening for gonorrhea infection
- Cervical cancer screening tests
- Pap tests of the cervix
- Human papillomavirus (HPV) tests of the cervix
- Pap tests of the cervix
- Screening for human immunodeficiency virus (HIV) infection
- Screening for syphilis infection
- Screening for latent tuberculosis infection for children ages 18 through 21
Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.
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 (except as noted below)
Note: For services billed by Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.
Note: We provide benefits for services billed by Participating/Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.
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