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 53 health crisis. Mobile crisis intervention is used: to identify, assess, treat, and stabilize a situation; to reduce the immediate risk of danger to the member or others; and to make referrals and linkages to all medically necessary behavioral health services and supports and the appropriate level of care. Mobile crisis intervention includes a crisis assessment and crisis planning, which may result in the development or update of a crisis safety plan. Your coverage for these services is considered to be an outpatient benefit. These intermediate treatments may be considered an inpatient benefit or an outpatient benefit. If you would normally pay a copayment for inpatient or outpatient benefits, the copayment will be waived when you get covered intermediate care. But, you must still pay your deductible and/or coinsurance, whichever applies. No benefits are provided for: a program for which Blue Cross Blue Shield HMO Blue is not able to conduct concurrent review of continued medical necessity (see Part 4), including a program that has a pre- defined length of care or stay; a program that provides only meetings or activities that are not based on an individualized treatment plan; and a program that focuses solely on the improvement of interpersonal or other skills, rather than on treatment that is focused on symptom reduction and functional recovery for specific mental conditions. Outpatient Services This health plan covers outpatient covered services to diagnose and/or treat mental conditions when the services are furnished for you by a mental health provider. This coverage is provided for as many visits as are medically necessary for your mental condition. (See “Preventive Health Services” for your coverage for outpatient mental health wellness exams.) Oxygen and Respiratory Therapy This health plan covers:  Oxygen and the equipment to administer it for use in the home. These items must be obtained from an oxygen supplier. This includes oxygen concentrators.  Respiratory therapy services. These services must be furnished for you by a covered provider. Some examples are: postural drainage; and chest percussion. Pain Management Alternatives to Opiates There are certain health care services or supplies that are covered by this health plan that are considered to be alternative treatments to opiates for pain management, when these covered services are furnished by a covered provider. Some examples of covered services include (but are not limited to):  Acupuncture services (see “Medical Care Outpatient Visits”).  Chiropractic services (see “Chiropractor Services”).  Devices such as transcutaneous electrical nerve stimulation (TENS) units and their related supplies (see “Durable Medical Equipment” for your coverage for durable medical equipment or covered supplies).