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 50
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 50
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Services determined to be not medically necessary
- Other services, supplies, or drugs provided to individuals not enrolled in this Plan, including surrogates
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Allergy Care
Note: See earlier in this section for applicable office visit copayment.
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 primary care provider or other healthcare professional: $35 copayment
Preferred specialist: $50 copayment
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 (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.
Allergy Care
- Allergy testing
- Allergy treatment
- Sublingual allergy desensitization drugs as licensed by the U.S. FDA
Note: See earlier in this section for applicable office visit copayment.
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 primary care provider or other healthcare professional: $35 copayment
Preferred specialist: $50 copayment
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 (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.
Benefit Description
Note: See earlier in this section for applicable office visit copayment.
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
- Allergy injections
Note: See earlier in this section for applicable office visit copayment.
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
Benefit Description
Note: See earlier in this section for applicable office visit copayment.
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 primary care provider or other healthcare professional: $35 copayment per multi-dose vial of antigen
Preferred specialist: $50 copayment per multi-dose vial of antigen
Participating/Non-participating: You pay all charges (except as noted below)
- Preparation of each multi-dose vial of antigen
Note: See earlier in this section for applicable office visit copayment.
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 primary care provider or other healthcare professional: $35 copayment per multi-dose vial of antigen
Preferred specialist: $50 copayment per multi-dose vial of antigen
Participating/Non-participating: You pay all charges (except as noted below)