Part 2 – Explanation of Terms (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 19  The improvement must be attainable outside the investigational setting. When used under the usual conditions of medical practice, the technology should be reasonably expected to improve health outcomes to a degree comparable to that published in the medical literature. Blue Cross Blue Shield HMO Blue may also, as part of a “pilot” program, cover new technologies that are not otherwise described as a covered service. In these cases, the technologies that are covered under the pilot program must: be approved by the FDA; have published clinical literature showing safety and efficacy; and be reasonably expected to improve health outcomes. Medically Necessary (Medical Necessity) To receive your health plan coverage, all of your health care services and supplies must be medically necessary and appropriate for your health care needs. (The only exceptions are for certain routine and preventive health care services that are covered by this health plan.) Blue Cross Blue Shield HMO Blue has the discretion to determine which health care services and supplies that you receive (or you are planning to receive) are medically necessary and appropriate for coverage. It will do this by referring to the guidelines described below. All health care services must be required services that a health care provider, using prudent clinical judgment, would provide to a patient in order to prevent or to evaluate or to diagnose or to treat an illness, injury, disease, or its symptoms. And, these health care services must also be:  Furnished in accordance with generally accepted standards of professional medical practice (as recognized by the relevant medical community);  Clinically appropriate, in terms of type, frequency, extent, site, and duration; and they must be considered effective for your illness, injury, or disease;  Consistent with the diagnosis and treatment of your condition and in accordance with Blue Cross Blue Shield HMO Blue medical policies and medical technology assessment criteria;  Essential to improve your net health outcome and as beneficial as any established alternatives that are covered by Blue Cross Blue Shield HMO Blue;  Consistent with the level of skilled services that are furnished and furnished in the least intensive type of medical care setting that is required by your medical condition; and  Not more costly than an alternative service or sequence of services at least as likely to produce the same therapeutic or diagnostic results to diagnose or treat your illness, injury, or disease. This does not include a service that: is primarily for your convenience or for the convenience of your family or the health care provider; is furnished solely for your religious preference; promotes athletic achievements or a desired lifestyle; improves your appearance or how you feel about your appearance; or increases or enhances your environmental or personal comfort. Member The term “you” refers to any member who has the right to the coverage provided by this health plan. A member may be the subscriber or their enrolled eligible spouse (or former spouse, if applicable) or any other enrolled eligible dependent. Mental Conditions This health plan provides coverage for treatment of psychiatric illnesses or diseases. These include substance use disorders (such as drug and alcohol addiction). The illnesses or diseases that qualify as mental conditions are listed in the latest edition, at the time you receive treatment, of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.