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 57 and needles are bought at the same time, you pay two copayments: one for the insulin; and one for the syringes and needles.)  Materials to test for the presence of sugar when they are ordered for you by a physician for home use. These include (but are not limited to): blood glucose monitoring strips; ketone strips; lancets; urine glucose testing strips; normal, low, and high calibrator solution/chips; and dextrostik or glucose test strips. (You may obtain these testing supplies from a covered pharmacy or appliance company.) See “Durable Medical Equipment” for your coverage for glucometers.  Insulin injection pens.  Insulin infusion pumps and related pump supplies. (You will obtain the insulin infusion pump from an appliance company instead of a pharmacy.)  Syringes and needles when they are medically necessary for you.  Drugs that do not require a prescription by law (“over-the-counter” drugs), if any, that are listed on the Blue Cross Blue Shield HMO Blue Drug Formulary as a covered drug. Your Pharmacy Program booklet will list the over-the-counter drugs that are covered, if there are any. Or, you can go online and log on to the Blue Cross Blue Shield HMO Blue Web site at www.bluecrossma.org.  Prescription birth control drugs and contraceptive methods (such as diaphragms) that have been approved by the U.S. Food and Drug Administration (FDA). As required by state law, this coverage is provided for up to a 3-month supply for the first fill of the covered drug or other method and up to a 12-month supply for additional fills of the same prescription. (The 12-month supply may be issued all at once or over the course of the 12-month period.) Your cost share will be waived for generic birth control drugs and methods (or for a brand-name drug or method when a generic is not available or not medically appropriate for you). This is the case even if your health plan is a grandfathered health plan under the Affordable Care Act. If you choose to use a brand-name birth control drug or method when a generic is available or appropriate for you, you will have to pay your cost share. See “Family Planning” for your coverage for contraceptive implant systems and IUDs.  Prescription prenatal vitamins and pediatric vitamins with fluoride.  Prescription dental topical fluoride, rinses, and gels.  Smoking and tobacco cessation products (this includes drugs and aids such as nicotine gum, patches, lozenges, inhaler systems, nasal sprays, and oral medications) for up to a 168-day supply for each type of product for each member in each calendar year, when they are prescribed for you by a health care provider. (These products are typically dispensed in lesser day supply quantities over the course of the calendar year.) Your cost share will be waived for generic products (or for a preferred brand-name product when a generic is not available), unless your health plan is a grandfathered health plan under the Affordable Care Act. If you choose to use a brand-name product when a generic is available, you will have to pay your cost share. Your coverage for “Preventive Health Services” includes smoking and tobacco cessation counseling as recommended by the U.S. Preventive Services Task Force, unless your health plan is a grandfathered health plan under the Affordable Care Act.  Prescription opioid antagonist drugs that block and reverse the effects of opioids that are used for the emergency treatment of a known or suspected overdose (such as morphine or heroin). Except for auto injection devices, this health plan will provide full in-network coverage for all forms of these covered drugs. (If out-of-network coinsurance applies for drugs and supplies, your out-of-network