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 43 Hospice Services This health plan covers hospice services when they are furnished (or arranged and billed) for you by a hospice provider. “Hospice services” means pain control and symptom relief and supportive and other care for a member who is terminally ill and expected to live 12 months or less. These services are furnished to meet the needs of the member and of their family during the illness and death of the member. They may be furnished at home, in the community, and in facilities. This coverage includes:  Services furnished and/or arranged by the hospice provider. These may include services such as: physician, nursing, social, volunteer, and counseling services; inpatient care; home health aide visits; drugs; and durable medical equipment.  Respite care. This care is furnished to the hospice patient in order to relieve the family or primary care person from care giving functions.  Bereavement services. These services are provided to the family or primary care person after the death of the hospice patient. They can include contacts, counseling, communication, and correspondence. Infertility Services This health plan covers services to diagnose and treat infertility for a member who has not been able to conceive or produce conception during a period of one year. Blue Cross Blue Shield HMO Blue may approve coverage for infertility services in two other situations: when the member has been diagnosed with cancer and, after treatment, the member is expected to become infertile; or when a member is age 35 or older and has not been able to conceive or produce conception during a period of six months. If a member conceives but cannot carry that pregnancy to live birth, the time period that the member tried to conceive prior to achieving that pregnancy will be included in the calculation of the one-year or six- month time period as described above. To receive coverage for infertility services, they must be medically necessary for you, furnished by a covered provider, and approved by Blue Cross Blue Shield HMO Blue as outlined in this Subscriber Certificate and in the Blue Cross Blue Shield HMO Blue medical policy. You and your health care provider must receive approval from Blue Cross Blue Shield HMO Blue before you obtain infertility services. Blue Cross Blue Shield HMO Blue will let you and your health care provider know when your coverage is approved. (See Part 4.) In all cases, covered services must conform with Blue Cross Blue Shield HMO Blue medical policy and meet Blue Cross Blue Shield HMO Blue medical technology assessment criteria. (See page 18 for help for how to access or obtain a copy of the medical policy.) This coverage may include (but is not limited to):  Artificial insemination.  Sperm and egg and/or inseminated egg procurement and processing.  Banking of sperm or inseminated eggs (only when they are not covered by the donor’s health plan); and other services as outlined in Blue Cross Blue Shield HMO Blue medical policy.  Infertility technologies, such as: in vitro fertilization and embryo placement; gamete intrafallopian transfer; zygote intrafallopian transfer; natural oocyte retrieval intravaginal fertilization; and intracytoplasmic sperm injection.