2024 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 55
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 55
Benefit Description
Foot Care (cont.)
Standard Option - You Pay
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Foot Care (cont.)
Standard Option - You Pay
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Benefit Description
Not covered: Routine foot care, such as cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered: Routine foot care, such as cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Orthopedic and Prosthetic Devices
Orthopedic braces and prosthetic appliances such as:
Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.
We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b).
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: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Orthopedic and Prosthetic Devices
Orthopedic braces and prosthetic appliances such as:
- Artificial limbs and eyes
- Functional foot orthotics when prescribed by a physician
- Rigid devices attached to the foot or a brace, or placed in a shoe
- Replacement, repair, and adjustment of covered devices
- Following a mastectomy, breast prostheses and surgical bras, including necessary replacements
- Surgically implanted penile prostheses limited to treatment of erectile dysfunction or as part of an approved plan for gender affirming surgery
- Surgical implants
Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.
We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b).
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: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Benefit Description
Note: Benefits for hearing aid dispensing fees, fittings, batteries, and repair services are included in the benefit limits described above. Prior approval is required for hearing aids.
Standard Option - You Pay
Any amount over $2,500 (no deductible)
Basic Option - You Pay
Any amount over $2,500
- Hearing aids for children up to age 22, limited to $2,500 per calendar year
- Hearing aids for adults age 22 and over, limited to $2,500 every 5 calendar years
Note: Benefits for hearing aid dispensing fees, fittings, batteries, and repair services are included in the benefit limits described above. Prior approval is required for hearing aids.
Standard Option - You Pay
Any amount over $2,500 (no deductible)
Basic Option - You Pay
Any amount over $2,500
Benefit Description
Standard Option - You Pay
Any amount over $5,000 (no deductible)
Basic Option - You Pay
Any amount over $5,000
- Bone-anchored hearing aids when medically necessary, limited to $5,000 per calendar year
Standard Option - You Pay
Any amount over $5,000 (no deductible)
Basic Option - You Pay
Any amount over $5,000
Benefit Description
Note: Benefits for wigs are paid at 100% of the billed amount, limited to $350 for one wig per lifetime.
Standard Option - You Pay
Any amount over $350 for one wig per lifetime (no deductible)
Basic Option - You Pay
Any amount over $350 for one wig per lifetime
- Wigs for hair loss due to the treatment of cancer
Note: Benefits for wigs are paid at 100% of the billed amount, limited to $350 for one wig per lifetime.
Standard Option - You Pay
Any amount over $350 for one wig per lifetime (no deductible)
Basic Option - You Pay
Any amount over $350 for one wig per lifetime
Orthopedic and Prosthetic Devices - continued on next page