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 54
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 54
Benefit Description
Vision Services (Testing, Treatment, and Supplies) (cont.)
Note: See Section 5(b), Surgical procedures, for coverage for surgical treatment of amblyopia and strabismus.
Note: See earlier in this section for our payment levels for Lab, X-ray, and other diagnostic tests performed or ordered by your provider.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment (no deductible)
Preferred specialist: $40 copayment (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
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $50 copayment per visit
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
Vision Services (Testing, Treatment, and Supplies) (cont.)
- Eye examinations related to a specific medical condition
- Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21
Note: See Section 5(b), Surgical procedures, for coverage for surgical treatment of amblyopia and strabismus.
Note: See earlier in this section for our payment levels for Lab, X-ray, and other diagnostic tests performed or ordered by your provider.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment (no deductible)
Preferred specialist: $40 copayment (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
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $50 copayment per visit
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
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses, except as previously described
- Deluxe eyeglass frames or lens features for eyeglasses or contact lenses such as special coating, polarization, UV treatment, etc.
- Multifocal, accommodating, toric, or other premium intraocular lenses (IOLs) including Crystalens, ReStor, and ReZoom
- Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described above
- LASIK, INTACS, radial keratotomy, and other refractive surgical services
- Refractions, including those performed during an eye examination related to a specific medical condition, except as described above
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Foot Care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
Note: See Orthopedic and Prosthetic Devices for information on podiatric shoe inserts.
Note: See Section 5(b) for our coverage for surgical procedures.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies)
Preferred specialist: $40 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $50 copayment per visit
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
Foot Care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
Note: See Orthopedic and Prosthetic Devices for information on podiatric shoe inserts.
Note: See Section 5(b) for our coverage for surgical procedures.
Standard Option - You Pay
Preferred primary care provider or other healthcare professional: $30 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies)
Preferred specialist: $40 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Basic Option - You Pay
Preferred primary care provider or other healthcare professional: $35 copayment per visit
Preferred specialist: $50 copayment per visit
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
Foot Care - continued on next page