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2023 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 59
 
Benefit Description

Medical Supplies (cont.)

 
  • 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:
 
  • Infant formulas used as a substitute for breastfeeding
     
  • Diabetic supplies, except as described in Section 5(f) or when Medicare Part B is primary
     
  • Medical foods administered orally, except as described in Section 5(f)


Standard Option - You Pay
All charges

Basic Option - You Pay
All charges
 
Benefit Description

Home Health Services

Home nursing care (skilled) for two hours per day when:
 
  • A registered nurse (R.N.) or licensed practical nurse (L.P.N.) provides the services; and
     
  • A physician orders the care


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

Note: Benefits for home nursing care are limited to 50 visits per person, per calendar year.

Note: Visits that you pay for while meeting your calendar year deductible count toward the annual visit limit.

Basic Option - You Pay
Preferred: $30 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 152 for more information about “agents.”)

Note: Benefits for home nursing care are limited to 25 visits per person, per calendar year.

Participating/Non-participating: You pay all charges
 
Benefit Description
Not covered:
 
  • Nursing care requested by, or for the convenience of, the patient or the patient’s family
     
  • Services primarily for bathing, feeding, exercising, moving the patient, homemaking, giving medication, or acting as a companion or sitter


Standard Option - You Pay
All charges

Basic Option - You Pay
All charges
 
Home Health Services - continued on next page
 
Go to page 58 , . Go to page 60.