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 63 (Any dollar benefit maximum does not apply for covered services related to the hearing aid.) As required by state law, this coverage is provided for at least $2,000 (for the hearing aid device itself) for one hearing aid for each hearing-impaired ear every 36 months for a member age 21 or younger (from birth through age 21). Routine Vision Care This health plan covers a periodic routine vision exam when it is furnished for you by an ophthalmologist or by an optometrist. The Schedule of Benefits for your plan option describes the benefit limit that applies for routine vision exams—this is the time period during which a routine vision exam will be covered by your health plan. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) Once you have received this coverage, no more benefits will be provided for another exam during the same time period. Vision Supplies Your health plan may also cover certain vision supplies and covered services related to covered vision supplies when they are furnished by a covered provider, such as an ophthalmologist or an optometrist. Your Schedule of Benefits will tell you whether or not you have coverage for vision supplies and related services. Your health plan may also include a rider to add or change coverage for vision supplies and related services. If this is the case, refer to your rider for information about your vision supply benefits. Prosthetic Devices This health plan covers prosthetic devices that you get from an appliance company, or from another provider who is designated by Blue Cross Blue Shield HMO Blue to furnish the covered prosthetic device. This coverage is provided for devices that are: used to replace the function of a missing body part; made to be fitted to your body as an external substitute; and not useful when you are not ill or injured. Some examples of covered prosthetic devices include (but are not limited to):  Artificial limb devices to replace (in whole or in part) an arm or a leg. This includes any repairs that are needed for the artificial leg or arm.  Artificial eyes.  Ostomy supplies; and urinary catheters.  Breast prostheses. This includes mastectomy bras.  Therapeutic/molded shoes and shoe inserts that are furnished for a member with severe diabetic foot disease.  One wig (scalp hair prosthesis) in each calendar year (but no less than $350 in coverage each calendar year, as required by state law) for a member whose hair loss is due to: chemotherapy; radiation therapy; infections; burns; traumatic injury; congenital baldness; and medical conditions resulting in alopecia areata or alopecia totalis (capitus). No benefits are provided for wigs when hair loss is due to: male pattern baldness; female pattern baldness; or natural or premature aging.