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 58
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 58
Benefit Description
Durable Medical Equipment (DME) (cont.)
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
Note: See Section 5(c) for our coverage of DME provided and billed by a facility.
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Note: See Section 5(c) for our coverage of DME provided and billed by a facility.
Durable Medical Equipment (DME) (cont.)
- 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
Note: See Section 5(c) for our coverage of DME provided and billed by a facility.
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating/Non-participating: You pay all charges
Note: See Section 5(c) for our coverage of DME provided and billed by a facility.
Benefit Description
Standard Option - You Pay
Any amount over $1,250 per year (no deductible)
Basic Option - You Pay
Any amount over $1,250 per year
- 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 described on page 48
- 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
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
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 - continued on next page