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 70 When medically appropriate outpatient telehealth services are furnished by a Blue Cross Blue Shield HMO Blue designated telehealth vendor, your cost share (such as deductible, copayment, and/or coinsurance) is the same as the lowest cost share level that you would pay for similar services when they are furnished by a preferred physician for outpatient medical care or by a preferred mental health provider for mental health and substance use care. 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.) Your cost share for covered outpatient telehealth services with a Blue Cross Blue Shield HMO Blue designated telehealth vendor may be lower than your in-person cost share with a covered provider. If this is the case, this will be described in a rider. Exception for covered services furnished by a virtual care team primary care provider type: When your specific plan option includes the “Virtual Care Team Model” rider, your cost share for outpatient telehealth services furnished by a Blue Cross Blue Shield HMO Blue designated telehealth vendor is not the same cost share for outpatient telehealth services as described above. For outpatient telehealth services furnished by a Blue Cross Blue Shield HMO Blue designated telehealth vendor, your cost share is the same as the lowest telehealth cost share that you would pay for covered services furnished by a preferred primary care provider type that is not a virtual care team primary care provider type as described in your Schedule of Benefits and/or riders that apply to your coverage in this health plan. When you are enrolled in an Options tiered network plan, the lowest telehealth cost share is the same as the Enhanced Benefits Tier cost share. Your cost share for covered outpatient telehealth services with a Blue Cross Blue Shield HMO Blue designated telehealth vendor may be lower than described in this paragraph. If this is the case, this will be described in a rider. TMJ Disorder Treatment This health plan covers outpatient services that are furnished for you by a covered provider to diagnose and/or treat temporomandibular joint (TMJ) disorders that are caused by or result in a specific medical condition (such as degenerative arthritis and jaw fractures or dislocations). The medical condition must be proven to exist by means of diagnostic x-ray tests or other generally accepted diagnostic procedures. This coverage includes:  Diagnostic x-rays.  Surgical repair or intervention.  Non-dental medical care services to diagnose and treat a TMJ disorder.  Splint therapy. (This also includes measuring, fabricating, and adjusting the splint.)  Physical therapy. (See “Short-Term Rehabilitation Therapy.”) No benefits are provided for: TMJ disorders that are not proven to be caused by or to result in a specific medical condition; appliances, other than a mandibular orthopedic repositioning appliance (MORA); and services, supplies, or procedures to change the height of teeth or otherwise restore occlusion (such as bridges, crowns, or braces).