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 44 If covered services are furnished outside of Massachusetts and the health care provider does not have a payment agreement with the local Blue Cross and/or Blue Shield Plan, this health plan will provide these benefits only when the provider is board certified and meets the appropriate American Society of Reproductive Medicine standards for an infertility provider. Otherwise, no benefits will be provided for the services furnished by those providers. Coverage for Prescription Drugs The drugs that are used for infertility treatment are covered by this health plan as a prescription drug benefit. This means that coverage will be provided for these covered drugs only when the drugs are furnished by a covered pharmacy, even if a non-pharmacy health care provider administers the drug for you during a covered visit. For your coverage for these covered drugs, see “Prescription Drugs and Supplies.” (There are no exclusions, limitations, or other restrictions for drugs prescribed to treat infertility that are different from those applied to drugs that are prescribed for other medical conditions.) No benefits are provided for: long term sperm or egg preservation or long term cryopreservation not associated with active infertility treatment; costs that are associated with achieving pregnancy through surrogacy (gestational carrier); infertility treatment that is needed as a result of a prior sterilization or unsuccessful sterilization reversal procedure (except for medically necessary infertility treatment that is needed after a sterilization reversal procedure that is successful as determined by appropriate diagnostic tests); and in vitro fertilization furnished for a fertile member to select the genetic traits of the embryo (coverage may be available for the genetic testing alone when the testing conforms with Blue Cross Blue Shield HMO Blue medical policy). Lab Tests, X-Rays, and Other Tests This health plan covers outpatient diagnostic tests, including prognostic or monitoring tests, when they are furnished by a covered provider. The results of these tests may lead to improvements in health outcomes. This health plan also covers medically necessary anesthesia services that may be required to perform covered outpatient diagnostic tests. This coverage includes:  Diagnostic lab tests. These tests normally use samples from the body such as blood, waste, or tissue. These tests allow providers to obtain information about a member’s health to help to diagnose or to treat or to prevent disease.  Diagnostic x-ray and other imaging tests, when they are not performed as part of a covered surgical admission. These tests provide a radiological image of the internal body. These types of tests can be low-tech radiology services, such as ultrasounds or x-rays. Or, they can be high-tech radiology services, such as computerized axial tomography (CT scans), magnetic resonance imaging (MRI), positron emission tomography (PET scans), and nuclear cardiac imaging. Imaging tests may pair pictures of the body with functional measurements, such as a barium swallow test.  Other diagnostic tests not described above. These tests are used: to confirm or diagnose health problems; to monitor a condition; and/or to determine a course of treatment. Some examples of diagnostic tests are: capsule endoscopy; transcranial doppler study; and diagnostic machine tests, such as pulmonary function tests and Holter monitoring.