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2025 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

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. Prior approval is required for hearing aids.

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

Orthopedic and Prosthetic Devices (cont.)

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), and hearing aids when prior approval was not obtained

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:

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

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

Durable Medical Equipment (DME) - continued on next page

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