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 34 Women’s Health and Cancer Rights As required by federal law, this coverage includes breast reconstruction in connection with a mastectomy. This health plan provides coverage for: all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prostheses and treatment of physical complications at all stages of mastectomy, including lymphedemas. These services will be furnished in a manner determined in consultation with the attending physician and the patient.  Transplants. This means human organ (or tissue) and stem cell (“bone marrow”) transplants that are furnished according to Blue Cross Blue Shield HMO Blue medical policy and medical technology assessment criteria. It also includes one or more stem cell transplants for a member who has been diagnosed with breast cancer that has spread and the member meets the standards that have been set by the Massachusetts Department of Public Health. For covered transplants, coverage also includes: the harvesting of the donor’s organ (or tissue) or stem cells when the recipient is a member; and drug therapy that is furnished during the transplant procedure to prevent the transplanted organ (or tissue) or stem cells from being rejected. “Harvesting” includes: the surgical removal of the donor’s organ (or tissue) or stem cells; and the related medically necessary services and/or tests that are required to perform the transplant itself. No benefits are 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. You must have a serious medical condition that requires that you be admitted to a hospital as an inpatient in order for the surgery to be safely performed. (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.)  Voluntary termination of pregnancy (abortion).  Voluntary sterilization procedures. To provide coverage for the women’s preventive health services as recommended by the U.S. Department of Health and Human Services and, as required by state law, any in-network deductible, copayment, and/or coinsurance, whichever applies to