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 57
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 57
Benefit Description
Durable Medical Equipment (DME) (cont.)
Standard Option - You Pay
Any amount over $1,250 per year (no deductible)
Basic Option - You Pay
Any amount over $1,250 per year
Durable Medical Equipment (DME) (cont.)
- Speech-generating devices, limited to $1,250 per calendar year
Standard Option - You Pay
Any amount over $1,250 per year (no deductible)
Basic Option - You Pay
Any amount over $1,250 per year
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Exercise and bathroom equipment
- Vehicle modifications, replacements, or upgrades
- Home modifications, upgrades, or additions
- Lifts, such as seat, chair, or van lifts
- Car seats
- Diabetic supplies, except as described in Section 5(f) or when Medicare Part B is primary
- Air conditioners, humidifiers, dehumidifiers, and purifiers
- Breast pumps, except as previously described
- Communications equipment, devices, and aids (including computer equipment) such as “story boards” or other communication aids to assist communication-impaired individuals (except for speech-generating devices as listed above)
- Equipment for cosmetic purposes
- Topical Hyperbaric Oxygen Therapy (THBO)
- Charges associated with separate or extended warranties
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Medical Supplies
Note: We cover medical supplies at Preferred benefit levels only when you use a Preferred medical supply provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred medical supply providers.
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
Medical Supplies
- Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
Note: See Section 10, Definitions, for more information about medical foods.
- Ostomy and catheter supplies
- Oxygen
Note: When billed by a skilled nursing facility, nursing home, or extended care facility, we pay benefits as shown here for oxygen, according to the contracting status of the facility.
- Blood and blood plasma, except when donated or replaced, and blood plasma expanders
Note: We cover medical supplies at Preferred benefit levels only when you use a Preferred medical supply provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred medical supply providers.
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
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Infant formulas used as a substitute for breastfeeding
- Diabetic supplies, except as described in Section 5(f) or when Medicare Part B is primary, or are enrolled in the FEP Medicare Prescription Drug Program
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Medical Supplies - continued on next page