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 62 Family Planning This health plan covers family planning services when they are furnished for you by a covered provider. This may include (but is not limited to): a physician; or a nurse practitioner; or a nurse midwife. This coverage includes:  Consultations, exams, procedures, and medical services related to the use of all contraceptive methods to prevent pregnancy that have been approved by the U.S. Food and Drug Administration (FDA).  Injection of birth control drugs. This includes a prescription drug when it is supplied during the visit.  Insertion of a contraceptive implant system (such as levonorgestrel or etonogestrel). This includes the implant system itself.  IUDs, diaphragms, and other prescription contraceptive methods that have been approved by the U.S. Food and Drug Administration (FDA), when the items are supplied during the visit.  Emergency contraception medications (over-the-counter; and prescription, when your prescription drug coverage is administered by Blue Cross Blue Shield HMO Blue). For these services, you may need to submit a claim as described in Part 9.  Genetic counseling. Important Note: You have the right to full in-network coverage for family planning services as required by state law. Or, if you choose to have these services performed by a non-preferred provider, you must pay your deductible, when it applies, and 20% coinsurance. No benefits are provided for: services related to achieving pregnancy through a surrogate (gestational carrier); and non-prescription birth control preparations (for example: condoms; birth control foams; jellies; and sponges). Routine Hearing Care Services This health plan covers:  Routine Hearing Exams and Tests. This includes routine hearing exams and tests furnished for you by a covered provider and newborn hearing screening tests for a newborn child (an infant under three months of age) as provided by regulations of the Massachusetts Department of Public Health. (See “Well Newborn Care” for your inpatient coverage for newborn hearing screening tests.)  Hearing Aids and Related Services. This includes hearing aids and covered services related to a covered hearing aid when the covered services are furnished by a covered provider, such as a licensed audiologist or licensed hearing instrument specialist. These covered services include: the initial hearing aid evaluation; one hearing aid for each hearing-impaired ear; fitting and adjustments of the hearing aid; and supplies such as (but not limited to) ear molds. No benefits are provided for replacement hearing aid batteries. The Schedule of Benefits for your plan option describes the benefit limit that applies for hearing aids—this means any age restriction, dollar benefit maximum for the hearing aid device itself, and/or eligible time period during which hearing aids and related services will be covered by your health plan. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) If you choose a hearing aid device that costs more than your benefit limit, you will have to pay the balance of the cost of the device that is in excess of the benefit limit.