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 58 coinsurance for these covered drugs will not be more than 20%.) For auto injection devices for these covered drugs, you will have to pay your cost share. Important Note: Any in-network deductible, copayment, and/or coinsurance (whichever applies to you) will be waived for certain preventive drugs as recommended and supported by the Health Resources and Services Administration and the U.S. Preventive Services Task Force. (If out-of-network coinsurance applies for drugs and supplies, your out-of-network coinsurance for these covered drugs will not be more than 20%.) The provisions described in this paragraph do not apply to you if your health plan is a grandfathered health plan under the Affordable Care Act. Non-Covered Drugs and Supplies No benefits are provided for:  Anorexiants; non-sedating antihistamines; ophthalmic drug solutions to treat allergies; inhaled topical nasal steroids; or proton pump inhibitors, except for prescription proton pump inhibitors that are prescribed for members under age 18 or that are prescribed as part of a combination drug used to treat helicobacter pylori. From time to time, Blue Cross Blue Shield HMO Blue may change this list of non-covered drugs and supplies. When a material change is made to this list of non-covered drugs and supplies, Blue Cross Blue Shield HMO Blue will let the subscriber (or the subscriber’s group on your behalf when you are enrolled in this health plan as a group member) know about the change at least 60 days before the change becomes effective. For more information, you can call the Blue Cross Blue Shield HMO Blue customer service office. The toll free phone number to call is shown on your ID card. Or, you can also go online and log on to the Blue Cross Blue Shield HMO Blue Web site at www.bluecrossma.org.  Pharmaceuticals that you can buy without a prescription, except as described in this Subscriber Certificate or in your Pharmacy Program booklet.  Medical supplies such as dressings and antiseptics.  The cost of delivering drugs to you.  Combination vitamins that require a prescription, except for: prescription prenatal vitamins; and pediatric vitamins with fluoride.  Drugs and supplies that you buy from a non-designated mail order pharmacy.  Drugs and supplies that you buy from any pharmacy that is not approved by Blue Cross Blue Shield HMO Blue for payment for the specific covered drug and/or supply. Preventive Health Services In this Subscriber Certificate, the term “preventive health services” refers to covered services that are performed to prevent diseases (or injuries) rather than to diagnose or treat a symptom or complaint, or to treat or cure a disease after it is present. This health plan provides coverage for preventive health services in accordance with applicable federal and state laws and regulations. Routine Pediatric Care This health plan covers routine pediatric care that is furnished by a covered provider and is in line with applicable Blue Cross Blue Shield HMO Blue medical policies. This coverage is limited to an age-based