Note: Preventive care benefits are not available for group counseling.
• Genetic counseling and evaluation for women whose family history is associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes Note: BRCA testing is covered only for members with a cancer diagnosis. See page 33 for the benefit levels that apply to diagnostic genetic testing.
• Screening for chlamydial infection
• Screening for gonorrhea infection
• Screening for Human Immunodeficiency virus (HIV) infection
• Screening for syphilis infection
• Administration and interpretation of a Health Risk Assessment (HRA) questionnaire (see Definitions) Note: As a member of the Service Benefit Plan, you have access to the Blue Cross and Blue Shield HRA, called the
“Blue Health Assessment” questionnaire. Completing the questionnaire entitles you to receive special benefit incentives. See Section 5(h) for complete information.
Note: Preventive care benefits for each of the services listed above are limited to one per calendar year.
Note: If the primary purpose of your office visit to a Preferred provider is other than preventive care, you pay the copayment amount shown on page 31. The
copayment applies even if you receive a covered preventive service during the visit.
Preferred: Nothing (No deductible)
Participating: 35% of the Plan allowance
Non-participating: 35% of the Plan allowance, 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.
Preferred: Nothing
Participating/Non-participating:
You pay all charges (except as noted below)
Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any
difference between our allowance and the billed amount.
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Note: Benefits are not available for routine physical examinations, associated laboratory tests, screening colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for aortic abdominal aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
• Colorectal cancer tests, including:
- Fecal occult blood test
- Screening colonoscopy (see page 53 for our payment levels for colonoscopies performed by a physician to diagnose or treat a specific condition)
- Sigmoidoscopy
- Double contrast barium enema
• Prostate cancer tests – Prostate Specific Antigen (PSA) test
• Cervical cancer tests (including Pap tests)
• Breast cancer tests (mammograms)
• Ultrasound for aortic abdominal aneurysm
• Osteoporosis screening – annual screening for women age 60 and over
Note: Preventive care benefits for each of the services listed above are limited to one per calendar year.
Preferred: Nothing (No deductible)
Participating: 35% of the Plan allowance
Non-participating: 35% of the Plan allowance, 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.
Preferred: Nothing
Participating/Non-participating:
You pay all charges (except as noted below)
Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any
difference between our allowance and the billed amount.
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Preventive care, adult - continued on next page
Preventive care, adult (cont.) Standard Option Basic Option
• Nutritional counseling when billed by a covered provider such as a physician, nurse, nurse practitioner, licensed certified nurse midwife, dietician or
nutritionist, who bills independently for nutritional counseling services
Note: Benefits are limited to individual nutritional counseling services. We do not provide benefits for group counseling services.
Note: If the primary purpose of your office visit to a Preferred provider is other than preventive care, you pay the copayment amount shown on page 31. The
copayment applies even if you receive a covered preventive service during the visit.
Preferred: Nothing (No deductible)
Participating: 35% of the Plan allowance
Non-participating: 35% of the Plan allowance, 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.
Preferred: Nothing
Participating/Non-participating:
You pay all charges (except as noted below)
Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any
difference between our allowance and the billed amount.
Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.
Note: Benefits are not available for routine physical examinations, associated laboratory tests, screening colonoscopies, or routine immunizations performed at Member or Non-member facilities.
Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for aortic abdominal aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.
Routine immunizations [as licensed by the U.S. Food and Drug Administration (FDA)], limited to:
• Hepatitis (Types A and B) for patients with increased risk or family history
• Herpes Zoster (shingles)*
• Human Papillomavirus (HPV)*
• Influenza (flu)*
• Measles, Mumps, Rubella
• Meningococcal*
• Pneumococcal*
• Tetanus, Diphtheria, Pertussis booster (one every 10 yrs)
• Varicella
*Many Preferred retail pharmacies participate in our vaccine network. See page 92 for our coverage of these vaccines when provided by pharmacies in the vaccine network.
Preferred: Nothing (No deductible)
Participating: 35% of the Plan allowance
Non-participating: 35% of the Plan allowance, plus any
difference between our allowance and the billed amount
Note: We waive your deductible and coinsurance amount for services billed by Participating/
Non-participating providers related to Influenza (flu) vaccines.
You pay any difference between our allowance and the billed amount.
Preferred: Nothing
Participating/Non-participating:
You pay all charges (except as noted below)
Note: We provide benefits for services billed by Participating/
Non-participating providers related to Influenza (flu) vaccines.
You pay 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.
Preventive care, adult - continued on next page
Preventive care, adult (cont.) Standard Option Basic Option
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.
Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed on page 35 to certain age ranges, frequencies, and/or other patient-specific indications, including gender.
Note: If the primary purpose of your office visit to a Preferred provider is other than preventive care, you pay the copayment amount shown on page 31. The
copayment applies even if you receive a covered preventive service during the visit.
Note: See page 92 for our payment levels for medicines to promote better health as recommended under the Affordable Care Act.
Note: The benefits listed above and on on pages 34-35 do not apply to children up to age 22. (See benefits under Preventive care, children, this Section.)
Note: A complete list of the preventive care services recommended under the Affordable Care Act is available online at: www.healthcare.gov/law/about/provisions/
services/lists.html. Services recommended under the Act and guidelines for health plan coverage are subject to Federal regulations.
See pages 34-35 See pages 34-35
Not covered:
• Genetic screening related to family history of cancer or other disease (see page 33 for our coverage of
medically necessary diagnostic genetic testing)
• Group counseling on prevention and reducing health risks
• 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
All charges All charges
Preventive care, children Standard Option Basic Option
We provide benefits for a comprehensive range of preventive care services for children up to age 22, including the preventive services recommended under the Patient Protection and Affordable Care Act (the
“Affordable Care Act”), and services recommended by the American Academy of Pediatrics (AAP). Covered services include:
• Healthy newborn visits and screenings (inpatient or outpatient)
Preferred: Nothing (No deductible)
Participating: 35% of the Plan allowance
Non-participating: 35% of the Plan allowance, plus any
difference between our allowance and the billed amount.
Preferred: Nothing
Participating/Non-participating:
You pay all charges (except as noted below)
Preventive care, children - continued on next page