WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 33 Part 5 Covered Services You have the right to the coverage described in this part, except as limited or excluded in other parts of this Subscriber Certificate. Also, be sure to read the Schedule of Benefits for your plan option. It describes the cost share amounts that you must pay for covered services. And, it shows the benefit limits that apply to specific covered services. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) Your coverage in this health plan consists of two benefit levels: one for in-network benefits; and one for out-of-network benefits. This means that your cost share amount differs based on the benefit level of the covered services that you receive. The highest benefit level is provided when you receive covered services from a covered provider who participates in your PPO health care network. This is your in-network benefit level. The lowest benefit level is usually provided when you receive covered services from a covered provider who does not participate in your PPO health care network. This is your out-of-network benefit level. Your out-of-network benefit level will be at least 80% of the in-network benefit level. This means that the coinsurance percentage for out-of-network benefits for non-emergency covered services will be no more than 20 percentage points greater than the coinsurance percentage for in-network benefits for the same covered services (excluding any reasonable deductible or copayment). The Schedule of Benefits for your plan option shows the cost share amounts that you will pay for in-network benefits and for out-of-network benefits. Admissions for Inpatient Medical and Surgical Care General and Chronic Disease Hospital Admissions Except for an admission for emergency medical care or for maternity care, you and your health care provider must receive approval from Blue Cross Blue Shield HMO Blue as outlined in this Subscriber Certificate before you enter a general or chronic disease hospital for inpatient care. Blue Cross Blue Shield HMO Blue will let you and your health care provider know when your coverage is approved. (See Part 4.) When inpatient care is approved by Blue Cross Blue Shield HMO Blue or it is for inpatient emergency medical care, this health plan provides coverage for as many days as are medically necessary for you. (For maternity care, see page 45.) This coverage includes:  Semiprivate room and board; and special services that are furnished for you by the hospital.  Surgery that is performed for you by a physician; or a podiatrist; or a nurse practitioner; or a dentist. This may also include the services of an assistant surgeon (physician) when Blue Cross Blue Shield HMO Blue decides that an assistant is needed. These covered services include (but are not limited to):  Reconstructive surgery. This means non-dental surgery that is meant to improve or give you back bodily function or to correct a functional physical impairment that was caused by: a birth defect; a prior surgical procedure or disease; or an accidental injury. It also includes surgery that is done to correct a deformity or disfigurement that was caused by an accidental injury. This coverage includes surgery to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome, when the covered provider has determined that this treatment is necessary to correct, repair, or lessen the effects of HIV associated lipodystrophy syndrome. These services include, but are not limited to: reconstructive surgery, such as suction-assisted lipectomy; other restorative procedures; and dermal injections or fillers for reversal of facial lipoatrophy syndrome.