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 56
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 56
Benefit Description
Orthopedic and Prosthetic Devices (cont.)
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Orthopedic and Prosthetic Devices (cont.)
Not covered:
- Shoes (including diabetic shoes)
- Over-the-counter orthotics
- Arch supports
- Heel pads and heel cups
- Wigs (including cranial prostheses), except for scalp hair prosthesis for hair loss due to the treatment of cancer, as stated above
- Over the counter hearing aids, enhancement devices, accessories or supplies (including remote controls and warranty packages), and hearing aids when prior approval was not obtained
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Durable Medical Equipment (DME)
Durable medical equipment (DME) is equipment and supplies that are:
We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:
Note: We cover DME at Preferred benefit levels only when you use a Preferred DME provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred DME 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
Durable Medical Equipment (DME)
Durable medical equipment (DME) is equipment and supplies that are:
- Prescribed by your attending physician (i.e., the physician who is treating your illness or injury);
- Medically necessary;
- Primarily and customarily used only for a medical purpose;
- Generally useful only to a person with an illness or injury;
- Designed for prolonged use; and
- Used to serve a specific therapeutic purpose in the treatment of an illness or injury.
We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:
- Home dialysis equipment
- Oxygen equipment
- Hospital beds
- Wheelchairs
- Crutches
- Walkers
- Continuous passive motion (CPM) devices
- Dynamic orthotic cranioplasty (DOC) devices
- Insulin pumps
- Other items that we determine to be DME, such as compression stockings
Note: We cover DME at Preferred benefit levels only when you use a Preferred DME provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred DME 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
Durable Medical Equipment (DME) - continued on next page