2024 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 51
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 51
Benefit Description
Orthopedic and Prosthetic Devices
Orthopedic braces and prosthetic appliances such as:
Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.
We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b).
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Orthopedic and Prosthetic Devices
Orthopedic braces and prosthetic appliances such as:
- Artificial limbs and eyes
- Functional foot orthotics when prescribed by a physician
- Rigid devices attached to the foot or a brace, or placed in a shoe
- Replacement, repair, and adjustment of covered devices
- Following a mastectomy, breast prostheses and surgical bras, including necessary replacements
- Surgically implanted penile prostheses limited to treatment of erectile dysfunction or as part of an approved plan for gender affirming surgery
- Surgical implants
Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.
We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b).
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Shoes (including diabetic shoes)
- Over-the-counter orthotics
- Arch supports
- Heel pads and heel cups
- Wigs (including cranial prostheses)
- Hearing aids, including bone anchored hearing aids, accessories or supplies (including remote controls and warranty packages) and all associated services
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:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (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
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Durable Medical Equipment (DME) - continued on next page