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 68 provided for the harvesting of the donor’s organ (or tissue) or stem cells when the recipient is not a member. (See “Lab Tests, X-Rays, and Other Tests” for your coverage for donor testing.)  Oral surgery. This means: reduction of a dislocation or fracture of the jaw or facial bone; excision of a benign or malignant tumor of the jaw; and orthognathic surgery that you need to correct a significant functional impairment that cannot be adequately corrected with orthodontic services. This coverage is provided when the surgery is furnished at a facility, provided that you have a serious medical condition that requires that you be admitted to a surgical day care unit of a hospital or to an ambulatory surgical facility in order for the surgery to be safely performed. This coverage is also provided when the surgery is furnished at an oral surgeon’s office. (Orthognathic surgery is not covered when it is performed mainly for cosmetic reasons. This surgery must be performed along with orthodontic services. If it is not, the oral surgeon must send a letter to Blue Cross Blue Shield HMO Blue asking for approval for the surgery. No benefits are provided for the orthodontic services, except as described in this Subscriber Certificate on page 38 for the treatment of conditions of cleft lip and cleft palate.) This health plan may also cover the removal of impacted teeth when the teeth are fully or partially imbedded in the bone. The Schedule of Benefits for your plan option will tell you whether or not you have coverage for these services. (Also refer to riders—if there are any—that apply to your coverage in this health plan.)  Internal prostheses (artificial replacements of parts of the body) that are furnished by the health care facility as part of a covered surgery such as intraocular lenses that are implanted after corneal transplant, cataract surgery, or other covered eye surgery, when the natural eye lens is replaced.  Non-dental surgery and necessary postoperative care that is furnished for you by a dentist who is licensed to furnish the specific covered service. (See Part 6, “Dental Care.”)  Necessary postoperative care that you receive after covered inpatient or outpatient surgery.  Anesthesia services that are related to covered surgery. This includes anesthesia that is administered by a physician other than the attending physician; or by a certified registered nurse anesthetist.  Restorative dental services and orthodontic treatment or prosthetic management therapy for a member who is under age 18 to treat conditions of cleft lip and cleft palate. (See page 38 for more information.) If a copayment normally applies for office surgery, the office visit copayment will be waived for these covered services. Any deductible and coinsurance will still apply. If a covered provider’s office is located at, or professional services are billed by, a hospital, your cost share is the same amount as for an office visit. Coverage for Self Injectable and Certain Other Drugs Furnished in an Office or Health Center There are self injectable and certain other prescription drugs used for treating your medical condition that are covered by this health plan only when these covered drugs are furnished by a covered pharmacy, even when a non-pharmacy health care provider administers the covered drug for you during a covered office