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 38 program; or services that are furnished, or that are required by law to be furnished, by a school or in a school-based setting. Cardiac Rehabilitation This health plan covers outpatient cardiac rehabilitation when it is furnished for you by a cardiac rehabilitation provider. You will be covered for as many visits as are medically necessary for your condition. This coverage is provided according to the regulations of the Massachusetts Department of Public Health. This means that your first visit must be within 26 weeks of the date that you were first diagnosed with cardiovascular disease. Or, you must start within 26 weeks after you have had a cardiac event. Blue Cross Blue Shield HMO Blue must determine through medical documentation that you meet one of these conditions: you have cardiovascular disease or angina pectoris; or you have had a myocardial infarction, angioplasty, or cardiovascular surgery. (This type of surgery includes: a heart transplant; or coronary bypass graft surgery; or valve repair or replacement.) For angina pectoris, this health plan covers only one course of cardiac rehabilitation for each member. No benefits are provided for: club membership fees; counseling services that are not part of your cardiac rehabilitation program (for example, these non-covered services may be educational, vocational, or psychosocial counseling); medical or exercise equipment that you use in your home; services that are provided to your family; and additional services that you receive after you complete a cardiac rehabilitation program. Chiropractor Services This health plan covers outpatient chiropractic services when they are furnished for you by a chiropractor who is licensed to furnish the specific covered service. This coverage includes: diagnostic lab tests (such as blood tests); diagnostic x-rays other than magnetic resonance imaging (MRI), computerized axial tomography (CT scans), and other imaging tests; and outpatient medical care services, including spinal manipulation. Your coverage for these services may have a benefit limit. If it does, the Schedule of Benefits for your plan option describes the benefit limit that applies for these covered services. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) Once you reach this benefit limit, no more benefits will be provided for these services. This is the case whether or not the service is medically necessary. Cleft Lip and Cleft Palate Treatment This health plan covers services to treat conditions of cleft lip and cleft palate for a member who is under age 18 (from birth through age 17). To receive coverage, these services must be furnished by a covered provider such as: a physician; a dentist; a nurse practitioner; a physician assistant; a licensed speech-language pathologist; a licensed audiologist; a licensed dietitian nutritionist; or a covered provider who has a recognized expertise in specialty pediatrics. These services may be furnished in the provider’s office or at a hospital or other covered facility. This coverage includes:  Medical, dental, oral, and facial surgery.  Surgical management and follow-up care by oral and plastic surgeons.