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 49 will apply to these covered services. Otherwise, any cost share amounts will not apply for these covered services. If you choose to obtain these covered services from a non-preferred provider, you must pay your deductible, when it applies, and 20% coinsurance. If a covered provider’s office is located at, or professional services are billed by, a hospital, your cost share is the same amount as for an office visit. Medical Formulas This health plan covers medical formulas and low protein foods to treat certain conditions. This coverage includes:  Special medical formulas that are approved by the Massachusetts Department of Public Health and are medically necessary for you to treat one of the listed conditions: homocystinuria; maple syrup urine disease; phenylketonuria; propionic acidemia; methylmalonic acidemia; or tyrosinemia.  Enteral formulas that you need to use at home and are medically necessary for you to treat malabsorption caused by one of the listed conditions: Crohn’s disease; chronic intestinal pseudo-obstruction; gastroesophageal reflux; gastrointestinal motility; ulcerative colitis; or inherited diseases of amino acids and organic acids.  Food products that are modified to be low protein and are medically necessary for you to treat inherited diseases of amino acids and organic acids. (You may buy these food products directly from a distributor.) Your benefits for these covered services are provided as a prescription drug benefit. See “Prescription Drugs and Supplies.” Mental Health and Substance Use Treatment This health plan covers medically necessary services to diagnose and/or treat mental conditions. This coverage includes:  Biologically-based mental conditions. “Biologically-based mental conditions” means: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder; delirium and dementia; affective disorders; eating disorders; post-traumatic stress disorders; autism; substance use disorders (such as drug and alcohol addiction); and any biologically-based mental conditions that appear in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders that are scientifically recognized and approved by the Commissioner of the Department of Mental Health.  Rape-related mental or emotional disorders for victims of a rape or victims of an assault with intent to rape.  Non-biologically-based mental, behavior, or emotional disorders of enrolled dependent children who are under age 19. This coverage includes pediatric specialty mental health care that is furnished by a mental health provider who has a recognized expertise in specialty pediatrics. (This coverage is not limited to those disorders that substantially interfere with or limit the way the child functions or how