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 60 medication; and age-appropriate screenings or observations to understand a covered member’s mental health history, personal history, and mental or cognitive state and, when appropriate, relevant adult input through screenings, interviews, and questions. Preventive Dental Care This health plan covers preventive dental care for a member who is under age 18 and who is being treated for conditions of cleft lip and cleft palate (see page 38). This coverage includes (but is not limited to) periodic oral exams, cleanings, and fluoride treatments furnished by a dentist or other covered provider. No benefits are provided for preventive dental care, except as described in this section. Routine Adult Physical Exams and Tests This health plan covers routine physical exams, routine tests, and other preventive health services when they are furnished for you by a covered provider in line with any applicable Blue Cross Blue Shield HMO Blue medical policies. This coverage includes:  Routine medical exams and related routine lab tests and x-rays. Your coverage for a routine physical exam is limited to one visit for each member in a calendar year.  Appropriate immunizations as recommended by the Advisory Committee on Immunization Practices. This coverage includes, but is not limited to: flu shots; and travel immunizations.  Blood tests to screen for lead poisoning as required by state law.  Routine mammograms as recommended and determined suitable by your health care provider. As required by state law, this coverage includes at least one baseline mammogram during the five-year period a member is age 35 through 39; and one routine mammogram each calendar year for a member who is age 40 or older. If you are determined to be at “high risk” for breast cancer, your health care provider may recommend a screening mammogram outside of these time periods.  Routine prostate-specific antigen (PSA) blood tests. This coverage is limited to one test each calendar year for a member who is age 40 or older.  Routine sigmoidoscopies and barium enemas.  Routine colonoscopies.  Preventive health services and screenings as recommended by the U.S. Preventive Services Task Force and the U.S. Department of Health and Human Services.  Diabetes prevention programs for members who have been diagnosed with pre-diabetes. The goal of these programs is to improve health and decrease the rate of progression to non-insulin dependent diabetes through structured health behavior changes, such as: dietary education; increased physical activity; and weight loss strategies. This coverage for diabetes prevention programs is limited to a lifetime benefit limit of one program for each eligible member.  Other routine services furnished in line with Blue Cross Blue Shield HMO Blue medical policies. Important Note: You have the right to full in-network coverage (provided the services are furnished by a preferred provider) for preventive health services as required by the Affordable Care Act and related regulations. For a complete description of these preventive health services, you can call the Blue Cross Blue Shield HMO Blue customer service office. The toll free phone number to call is shown on your ID