Table of Contents (continued) iii Inpatient Services............................................................................................................................50 Intermediate Treatments .................................................................................................................50 Outpatient Services.........................................................................................................................53 Oxygen and Respiratory Therapy ........................................................................................................53 Pain Management Alternatives to Opiates...........................................................................................53 PANS/PANDAS Treatment.................................................................................................................54 Podiatry Care........................................................................................................................................54 Prescription Drugs and Supplies..........................................................................................................54 Preventive Health Services ..................................................................................................................58 Routine Pediatric Care....................................................................................................................58 Routine Adult Physical Exams and Tests.......................................................................................60 Routine Gynecological (GYN) Exams ...........................................................................................61 Family Planning..............................................................................................................................62 Routine Hearing Care Services.......................................................................................................62 Routine Vision Care........................................................................................................................63 Prosthetic Devices................................................................................................................................63 Qualified Clinical Trials for Treatment of Cancer...............................................................................64 Radiation Therapy and Chemotherapy ................................................................................................65 Second Opinions ..................................................................................................................................65 Short-Term Rehabilitation Therapy.....................................................................................................65 Speech, Hearing, and Language Disorder Treatment ..........................................................................66 Surgery as an Outpatient......................................................................................................................66 Telehealth Services ..............................................................................................................................69 TMJ Disorder Treatment......................................................................................................................70 Part 6 Limitations and Exclusions ...........................................................................................71 Admissions That Start Before Effective Date......................................................................................71 Benefits from Other Sources................................................................................................................71 Cosmetic Services and Procedures ......................................................................................................71 Custodial Care......................................................................................................................................71 Dental Care ..........................................................................................................................................72 Educational Testing and Evaluations...................................................................................................72 Exams or Treatment Required by a Third Party ..................................................................................72 Experimental Services and Procedures................................................................................................72 Eyewear................................................................................................................................................72 Medical Devices, Appliances, Materials, and Supplies.......................................................................72 Missed Appointments ..........................................................................................................................73 Non-Covered Providers........................................................................................................................73 Non-Covered Services .........................................................................................................................73 Personal Comfort Items .......................................................................................................................74 Private Room Charges .........................................................................................................................74 Services and Supplies Furnished After Termination Date...................................................................74 Services Furnished to Immediate Family.............................................................................................75 Part 7 Other Party Liability.......................................................................................................76 Coordination of Benefits (COB)..........................................................................................................76 Blue Cross Blue Shield HMO Blue’s Rights to Recover Benefit Payments .......................................76 Subrogation and Reimbursement of Benefit Payments..................................................................76 Member Cooperation......................................................................................................................77 Workers’ Compensation ......................................................................................................................77