Note: Preventive care benefits for each of the services listed above are limited to one per calendar year.
Preferred: Nothing (No deductible)
Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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 Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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
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 59 for our payment levels for colonoscopies performed by a physician to diagnose or treat a specific condition)
- Sigmoidoscopy
- Double contrast barium enema
Preferred: Nothing (No deductible)
Participating: 35% of the Plan allowance
Preferred: Nothing
Participating/Non-participating:
You pay all charges (except as noted below)
Preventive care, adult - continued on next page
Preventive care, adult (cont.) Standard Option Basic Option
• Prostate cancer tests – Prostate Specific Antigen (PSA) test
• Cervical cancer tests (including Pap tests)
• Screening 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.
• 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 you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
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
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
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)
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.
Preventive care, adult - continued on next page
Preventive care, adult (cont.) Standard Option Basic Option
*Many Preferred retail pharmacies participate in our vaccine network. See page 98 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.
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: 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.
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 you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.
Note: See page 99 for our payment levels for medicines to promote better health as recommended under the Affordable Care Act.
Note: The benefits listed above and on pages 37-38 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 37-38 See pages 37-38
Not covered:
• Genetic screening (including BRCA screening) related to family history of cancer or other disease
All charges All charges
Preventive care, adult - continued on next page
Preventive care, adult (cont.) Standard Option Basic Option
Note: See page 36 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)
• Routine physical examinations
• Laboratory tests
• Hearing and vision screenings
• Routine immunizations as licensed by the U.S.
Food and Drug Administration (FDA) limited to:
- Diphtheria, Tetanus, Pertussis - Hemophilus Influenza type b (Hib) - Hepatitis (Types A and B)
- Human Papillomavirus (HPV) - Inactivated Poliovirus - Measles, Mumps, Rubella
Note: U.S. FDA licensure may restrict the use of certain immunizations and vaccines to specific age ranges, frequencies, and/or other patient-specific indications, including gender.
• Screening for chlamydial infection
• Screening for gonorrhea infection
• Screening for Human Papillomavirus (HPV) for females
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 the 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.
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.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: 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, children - continued on next page