54

This brochure version is for internal use only.

2023 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 54

Benefit Description

Durable Medical Equipment (DME) (cont.)

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

You Pay
All charges

Benefit Description

Medical Supplies
Covered medical supplies include:

Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
Note: See page 131 for the definition of medical foods.
Ostomy and catheter supplies
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. See page 77 for outpatient services received while in a skilled nursing 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.

You Pay
Preferred: 30% of the Plan allowance (deductible applies)

Non-preferred (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)

You Pay
All charges

Benefit Description

Home Health Services
Home nursing care (skilled) for two hours per day limited to 10 visits when:

A registered nurse (R.N.) or licensed practical nurse (L.P.N.) provides the services; and
A physician orders the care.

You Pay
Preferred: $25 copayment per visit (no deductible)

Non-preferred (Participating/Non-participating): You pay all charges

Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 128 for more information about “agents.”)

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

You Pay
All charges

Home Health Services - continued on next page

Go to page 53. Go page 55.