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 42 Blue Shield HMO Blue before you obtain services. Blue Cross Blue Shield HMO Blue will let you and your health care provider know when your coverage is approved. (See Part 4.) In all cases, covered services must conform with Blue Cross Blue Shield HMO Blue medical policy and meet Blue Cross Blue Shield HMO Blue medical technology assessment criteria. To access or obtain a copy of the medical policies for gender affirming services and other related covered services, you can:  Go online and log on to the Blue Cross Blue Shield HMO Blue Web site at www.bluecrossma.org. (Your health care provider can also access the policy by using the Blue Cross Blue Shield HMO Blue provider Web site.)  Call the Blue Cross Blue Shield HMO Blue customer service office. The toll free phone number to call is shown on your ID card. You can ask them to mail a copy of this medical policy to you. Home Health Care This health plan covers home health care when it is furnished (or arranged and billed) for you by a home health care provider. This coverage is provided only when: you are expected to reach a defined medical goal that is set by your attending physician; the “home” health care is furnished at a place where you live (unless it is a hospital or other health care facility that furnishes skilled nursing or rehabilitation services); and, for medical reasons, you are not reasonably able to travel to another treatment site where medically appropriate care can be furnished for your condition. This coverage includes:  Part-time skilled nursing visits; physical, speech/language, and occupational therapy; medical social work; nutrition counseling; home health aide services; medical supplies; durable medical equipment; enteral infusion therapy; and basic hydration therapy.  Home infusion therapy that is furnished for you by a home infusion therapy provider. This includes: the infusion solution; the preparation of the solution; the equipment for its administration; and necessary part-time nursing. This coverage includes long-term antibiotic therapy treatment for a member who has been diagnosed with Lyme disease when the treatment is determined by a licensed physician to be medically necessary and is ordered after a complete evaluation of the member’s: symptoms; results of diagnostic lab tests; or response to treatment. When physical, speech/language, and/or occupational therapy is furnished as part of your covered home health care program, a benefit limit will not apply to these services. No benefits are provided for: meals, personal comfort items, and housekeeping services; custodial care; services to treat mental conditions as described in this Subscriber Certificate for “Mental Health and Substance Use Treatment”; and home infusion therapy, including the infusion solution, when it is furnished by a pharmacy or other health care provider that is not a home infusion therapy provider. (The only exception is for enteral infusion therapy and basic hydration therapy that is furnished by a home health care provider.)