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 57

Benefit Description

Orthopedic and Prosthetic Devices (cont.)
 

• 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.


Standard Option - You Pay
Any amount over $2,500 (no deductible)

Basic Option - You Pay
Any amount over $2,500

Benefit Description
 

• 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
 

• 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

Benefit Description
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)

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:
 

1. Prescribed by your attending physician (i.e., the physician who is treating your illness or injury);
    
2. Medically necessary;
    
3. Primarily and customarily used only for a medical purpose;
    
4. Generally useful only to a person with an illness or injury;
    
5. Designed for prolonged use; and
    
6. 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

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) - continued on next page

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