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 45  Preoperative tests. These tests must be performed before a scheduled inpatient or surgical day care unit admission for surgery. And, they must not be repeated during the admission. Some examples of these tests are: diagnostic lab tests; diagnostic x-ray and other imaging tests; and diagnostic machine tests.  Human leukocyte antigen testing or histocompatibility locus antigen testing. These tests are necessary to establish stem cell (“bone marrow”) transplant donor suitability. They include testing for A, B, or DR antigens or any combination according to the guidelines of the Massachusetts Department of Public Health. If a copayment normally applies to these covered services, the copayment will not apply to the interpretation costs that are billed in conjunction with any one of the tests; and it will be waived when the tests are furnished during an emergency room visit or during a day surgery admission, or at a hospital and the results of the lab test(s) are required right away so the hospital can furnish treatment to you. You can call the Blue Cross Blue Shield HMO Blue customer service office for information about the times when your copayment may be waived. The toll free phone number to call is shown on your ID card. Your Schedule of Benefits describes your cost share amount. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) Maternity Services and Well Newborn Care Maternity Services This health plan covers all medical care that is related to pregnancy and childbirth (or miscarriage) when it is furnished for you by a covered provider. This coverage includes:  Semiprivate room and board and special services when you are an inpatient in a general hospital. This includes nursery charges for a well newborn. These charges are included with the benefits for the maternity admission. Your (and your newborn child’s) inpatient stay will be no less than 48 hours following a vaginal delivery or 96 hours following a Caesarian section unless you and your attending physician decide otherwise as provided by law. If you choose to be discharged earlier, this health plan covers one home visit within 48 hours of discharge, when it is furnished by a physician; or by a registered nurse; or by a nurse midwife; or by a nurse practitioner. This visit may include: parent education; assistance and training in breast or bottle feeding; and appropriate tests. This health plan will cover more visits that are furnished by a covered provider only if Blue Cross Blue Shield HMO Blue determines the visits are clinically necessary.  Outpatient maternity admissions in a licensed outpatient birthing center for a vaginal delivery. This includes nursery charges for a well newborn. These charges are included with the benefits for the maternity admission. Upon discharge, this health plan covers one home visit within 48 hours, when it is furnished by a physician; or by a registered nurse; or by a nurse midwife; or by a nurse practitioner. This visit may include: parent education; assistance and training in breast or bottle feeding; and appropriate tests. This health plan will cover more visits that are furnished by a covered provider only if Blue Cross Blue Shield HMO Blue determines the visits are clinically necessary. For these covered admissions, you will pay the cost share amount that is described in your Schedule of Benefits for outpatient maternity services furnished at a facility. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) There may be times when your condition requires you to be