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 39  Speech therapy, audiology services, and nutrition services.  Orthodontic treatment.  Preventive and restorative dental care to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management therapy. Your coverage for these covered services is provided to the same extent as coverage is provided for similar covered services to treat other physical conditions. COVID-19 Testing and Treatment This health plan covers services to diagnose or treat the 2019 novel coronavirus disease (COVID-19) when the services are furnished by a preferred provider or a non-preferred provider. This coverage includes inpatient or outpatient services such as:  Emergency medical care, including emergency ambulance transport.  Hospital or other covered health care facility services.  Cognitive rehabilitation services.  Professional, diagnostic, and laboratory services.  Medically necessary COVID-19 testing, including testing for asymptomatic members according to guidelines set by the Commonwealth of Massachusetts Secretary of the Executive Office of Health and Human Services. As required by state law, any deductible, copayment, and/or coinsurance, whichever applies to you, will be waived for diagnosis and treatment related to COVID-19 when the services are performed by a preferred provider or a non-preferred provider. There is one exception. When you are enrolled in a high deductible health plan with a health savings account, your deductible will apply to these covered services. Otherwise, any cost share amounts will not apply for these covered services. These covered services also include covered drugs and supplies that are furnished by a covered pharmacy when your prescription drug coverage is provided under this health plan. If a benefit limit would normally apply to any of the covered services listed above, a benefit limit will not apply for covered services to diagnose or treat COVID-19. Dialysis Services This health plan covers outpatient dialysis when it is furnished for you by a hospital; or by a community health center; or by a free-standing dialysis facility; or by a physician. This coverage also includes home dialysis when it is furnished under the direction of a covered provider. Your home dialysis coverage includes: non-durable medical supplies (such as dialysis membrane and solution, tubing, and drugs that are needed during dialysis); the cost to install the dialysis equipment in your home; and the cost to maintain or to fix the dialysis equipment. No home dialysis benefits are provided for: costs to get or supply power, water, or waste disposal systems; costs of a person to help with the dialysis procedure; and costs that are not needed to run the dialysis equipment.