Part 8 – Other Health Plan Provisions (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 80 certain covered services such as your copayment or your deductible or your coinsurance. When Blue Cross Blue Shield HMO Blue makes a material change to your coverage in this health plan, Blue Cross Blue Shield HMO Blue will send a notice about the change at least 60 days before the effective date of the change. The notice will be sent to the subscriber or, when you are enrolled in this health plan as a group member, to the plan sponsor. The notice from Blue Cross Blue Shield HMO Blue will describe the change being made. It will also give the effective date of the change. If you are enrolled as a group member, the plan sponsor should deliver to its group members all notices from Blue Cross Blue Shield HMO Blue. (If you enrolled in this health plan through the Massachusetts Health Connector, see Part 11 or Part 12, whichever applies to you, for information.) There may be times when the provisions of your coverage in this health plan change but Blue Cross Blue Shield HMO Blue is not able to provide prior notice of the change as described above. These changes may be made by Blue Cross Blue Shield HMO Blue as a result of events beyond its control such as: war; riot; national emergency; terrorist attack; public health emergency; pandemic; or natural disaster. When this happens, Blue Cross Blue Shield HMO Blue will make a determination to provide services under this health plan based on the severity of the event and the needs of its members enrolled under this health plan during this time. For example, Blue Cross Blue Shield HMO Blue may temporarily eliminate the cost share amount that you must pay for certain covered services such as your copayment or your deductible or your coinsurance. Charges for Non-Medically Necessary Services You may receive health care services that would otherwise be covered by this health plan, except that these services are not determined to be medically necessary for you by Blue Cross Blue Shield HMO Blue. This health plan does not cover health care services or supplies that are not medically necessary for you. If you receive care that is not medically necessary for you, you might be charged for the care by the health care provider. A provider who has a payment agreement with Blue Cross Blue Shield HMO Blue has agreed not to charge you for services that are not medically necessary, unless you were told, knew, or reasonably should have known before you received this treatment that it was not medically necessary. Clinical Guidelines and Utilization Review Criteria Blue Cross Blue Shield HMO Blue applies medical technology assessment criteria and medical necessity guidelines when it develops its clinical guidelines, utilization review criteria, and medical policies. Blue Cross Blue Shield HMO Blue reviews its clinical guidelines, utilization review criteria, and medical policies from time to time. Blue Cross Blue Shield HMO Blue does this to reflect new treatments, applications, and technologies. For example, when a new drug is approved by the U.S. Food and Drug Administration (FDA), Blue Cross Blue Shield HMO Blue reviews its safety, effectiveness, and overall value on an ongoing basis. While a new treatment, technology, or drug is being reviewed, it will not be covered by this health plan. Another example is when services and supplies are approved by the U.S. Food and Drug Administration (FDA) for the diagnosis and treatment of insulin dependent, insulin using, gestational, or non-insulin dependent diabetes. In this case, coverage will be provided for those services or supplies as long as they can be classified under a category of covered services.