Part 2 – Explanation of Terms (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 14 Covered Services This Subscriber Certificate and your Schedule of Benefits describe the health care services and supplies for which Blue Cross Blue Shield HMO Blue will provide coverage for you while you are enrolled in this health plan. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) These health care services and supplies are referred to as “covered services.” Except as described otherwise in this Subscriber Certificate, all covered services must be medically necessary for you, furnished by covered providers and, when it is required, approved by Blue Cross Blue Shield HMO Blue. Custodial Care Custodial care is a type of care that is not covered by Blue Cross Blue Shield HMO Blue. Custodial care means any of the following:  Care that is given primarily by medically-trained personnel for a member who shows no significant improvement response despite extended or repeated treatment; or  Care that is given for a condition that is not likely to improve, even if the member receives attention of medically-trained personnel; or  Care that is given for the maintenance and monitoring of an established treatment program, when no other aspects of treatment require an acute level of care; or  Care that is given for the purpose of meeting personal needs which could be provided by persons without medical training, such as assistance with mobility, dressing, bathing, eating and preparation of special diets, and taking medications. Custodial care does not include the habilitation services that are described as a covered service in Part 5. Deductible For some covered services, you may have to pay a deductible before you will receive benefits from this health plan. When your plan option includes a deductible, the amount that is put toward your deductible is generally calculated based on the health care provider’s actual charge or the Blue Cross Blue Shield HMO Blue allowed charge, whichever is less (unless otherwise required by law). As required by federal law for “surprise billing,” any deductible that applies for certain covered services that are furnished by non-preferred providers will be calculated based on the recognized amount and will contribute toward satisfying your in-network deductible (see Part 2, “Allowed Charge” for an explanation of these services). Your ID card and the Schedule of Benefits for your plan option show the amount of your deductible (if there is one). Your Schedule of Benefits also shows those covered services for which you must pay the deductible before you receive benefits. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) When a deductible does apply, there are some costs that you pay that do not count toward the deductible. These costs that do not count toward the deductible are:  Any copayments and/or coinsurance you pay.  The costs you pay when your coverage is reduced or denied because you did not follow the requirements of the Blue Cross Blue Shield HMO Blue utilization review program. (See Part 4.)  The costs you pay that are more than the Blue Cross Blue Shield HMO Blue allowed charge.  The costs you pay because your health plan has provided all of the benefits it allows for that covered service. (There may be certain times when amounts that you have paid toward a deductible under a prior health plan or contract may be counted toward satisfying your deductible under this health plan. To see if this applies to you, you can call the Blue Cross Blue Shield HMO Blue customer service office.)