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 59 schedule and a maximum number of visits. The Schedule of Benefits for your plan option describes the age-based schedule and the visit limits that apply for these covered services. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) As required by state law, this coverage is provided for at least: six visits during the first year of life (birth to age one, including inpatient visits for a well newborn); three visits during the second year of life (age one to age two); and one visit in each calendar year from age two through age five (until age 6). This coverage includes:  Routine medical exams; history; measurements; sensory (vision and auditory) screening; and neuropsychiatric evaluation and development screening; and assessment.  Hereditary and metabolic screening at birth.  Appropriate immunizations as recommended by the Advisory Committee on Immunization Practices. This includes, but is not limited to: flu shots; and travel immunizations.  Tuberculin tests; hematocrit, hemoglobin, and other appropriate blood tests; urinalysis; and blood tests to screen for lead poisoning (as required by state law).  Preventive health services and screenings as recommended by the U.S. Preventive Services Task Force and the U.S. Department of Health and Human Services.  Other routine services furnished in line with Blue Cross Blue Shield HMO Blue medical policies. For an enrolled child who receives coverage for vaccines from a federal or state agency, this health plan provides coverage only to administer the vaccine. Otherwise, this health plan also provides coverage for a covered vaccine along with the services to administer the vaccine. Important Note: You have the right to full in-network coverage (provided the services are furnished by a preferred provider) for preventive health services as required by the Affordable Care Act and related regulations. For a complete description of these preventive health services, 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. 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. No benefits are provided for exams that are needed: to take part in school, camp, and sports activities; or by third parties. The only exception to this is when these exams are furnished as a covered routine exam. Annual Mental Health Wellness Exams This health plan covers mental health wellness exams for at least one exam for each member in each calendar year. This coverage may be furnished by a covered provider, including mental health providers. As required by state law, this health plan provides full coverage for these covered services. You pay nothing for in-network and out-of-network benefits. (Any deductible, copayment, and/or coinsurance that you would normally pay will not apply.) A mental health wellness exam is a screening or assessment that seeks to identify any behavioral or mental health needs and appropriate resources for treatment. The exam may include: observation, a behavioral health screening, education and consultation on healthy lifestyle changes, referrals to ongoing treatment, mental health services and other necessary supports, and discussion of potential options for