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Active Members Information: Durable Medical Equipment (DME)

Prosthetics, Orthotics, Diabetic and Medical Supplies

DME, prosthetics, orthotics and medical supply services are provided by the medical plans.

• DME includes equipment such as wheelchairs, oxygen, hospital beds, walkers, crutches and braces, etc.
• Prosthetics and Orthotics (P&O) include artificial limbs, braces (such as leg and back braces), breast prostheses and medically-necessary shoe inserts for diabetics
• Medical supplies includes urological and ostomy supplies
• Diabetic supplies include syringes, needles, lancets, test strips, pumps and glucometers (Members should obtain insulin under the Prescription Drug Plan)

For Custom HMO Members: You must obtain your DME items and supplies from a network supplier. You have no coverage if you go to a supplier that does not participate with your Custom HMO.

For PPO Members: You have both a Network and an Out-of-Network benefit.

Covered Medically Necessary equipment and supplies obtained from a network supplier, as determined by your medical plan, are paid at 100% of the eligible covered expense.

Covered Medically Necessary equipment and supplies obtained from an Out-of-Network supplier, as determined by your medical plan, are paid at 70% of the UCR allowance up to the Out-of-Pocket Maximum for Out-of-Network services. You may also be responsible for the difference between the actual amount billed by the Out-of-Network supplier and the plan’s allowed amount.

NOTE: Equipment or supplies dispensed in a physician’s office or emergency room setting, provided as part of Home Health Care, Skilled Nursing Facility care or Hospice services; or as part of covered dialysis and home dialysis will be paid by your PPO at 100% after Deductible, if it is billed by the Provider and not by a DME supplier. Your Provider may dispense the equipment and will bill your PPO. For example, if you receive a knee brace or crutches at the emergency room, it is paid at 100% after Deductible. If your doctor writes a prescription for a DME item, you should obtain it from a Network supplier to get the highest level of benefits.

For Bronze Plan Members: You have both a Network and an Out-of-Network benefit, which are both subject to your annual deductible.

Covered, Medically Necessary equipment and supplies obtained from a Network Provider, as determined by your medical plan, are paid at 100% of the eligible covered expense after Deductible and OOP Max.

Covered Medically Necessary equipment and supplies obtained from an Out-of-Network Provider, as determined by your medical plan, are paid at 70% of the UCR allowance up to the Out-of-Pocket Maximum for Out-of-Network services.

Your medical plan will provide coverage for the rental or purchase of DME and Prosthetics exceeding a rental or purchase price of $100 (or other dollar threshold as may be established by your medical plan in accordance with its DME policy). Preauthorization is required for the rental of any DME item and the purchase of all DME and P&O devices.

Contact your medical plan with questions or to find a network DME supplier. The phone number appears on your medical plan ID card.

For more information, refer to your Summary Plan Description or contact PEBTF.