Part 5 – Covered Services (continued) IMPORTANT: Refer to the Schedule of Benefits for your plan option for the cost share amounts that you must pay for covered services and for the benefit limits that may apply to specific covered services. Once you reach your benefit limit for a specific covered service, no more benefits are provided by Blue Cross Blue Shield HMO Blue for those services or supplies. WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 40 Durable Medical Equipment This health plan covers durable medical equipment or covered supplies that you buy or rent from a covered provider that is an appliance company or from another provider who is designated by Blue Cross Blue Shield HMO Blue to furnish the specific covered equipment or supply. This coverage is provided for equipment or supplies that in most cases: can stand repeated use; serves a medical purpose; is medically necessary for you; is not useful if you are not ill or injured; and can be used in the home. Some examples of covered durable medical equipment include (but are not limited to):  Knee braces; back braces; and foot-worn medical devices that help to relieve pain associated with osteoarthritis and other musculoskeletal conditions by restoring alignment and improving walking patterns.  Orthopedic and corrective shoes that are part of a leg brace.  Hospital beds; wheelchairs; crutches; and walkers.  Glucometers. These are covered when the device is medically necessary for you due to your type of diabetic condition. (See “Prescription Drugs and Supplies” for your coverage for diabetic testing materials.)  Visual magnifying aids; and voice-synthesizers. These are covered only for a legally blind member who has insulin dependent, insulin using, gestational, or non-insulin dependent diabetes.  Insulin injection pens. (Your benefits for these items are provided as a prescription drug benefit when you buy them from a pharmacy. See “Prescription Drugs and Supplies.”) These covered services include one breast pump for each birth (other than a hospital grade breast pump) that you buy or rent from an appliance company or from a provider who is designated by Blue Cross Blue Shield HMO Blue to furnish breast pumps. However, your coverage will not be more than the full allowed charge for the purchase price of a breast pump. Coverage is also provided for breastfeeding equipment (including pump parts and maintenance) and breast milk storage supplies. If an in-network deductible and/or coinsurance would normally apply to any of these covered services, both the deductible and coinsurance will be waived for your in-network benefits. Or, if you choose to obtain any of these covered services from a non-preferred provider, you must pay your deductible, when it applies, and 20% coinsurance. (If your health plan is a grandfathered health plan under the Affordable Care Act, a deductible and/or coinsurance that would normally apply to you for durable medical equipment will still apply for a covered breast pump.) No benefits are provided for a hospital grade breast pump. From time to time, the equipment or supplies that are covered by this health plan may change. This change will be based on Blue Cross Blue Shield HMO Blue’s periodic review of its medical policies and medical technology assessment criteria to reflect new applications and technologies. You can call the Blue Cross Blue Shield HMO Blue customer service office for help to find out what is covered. (See Part 1.) Blue Cross Blue Shield HMO Blue will decide whether to rent or buy durable medical equipment. If Blue Cross Blue Shield HMO Blue decides to rent the equipment, your benefits will not be more than the amount that would have been covered if the equipment were bought. This health plan covers the least