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22 <br /> covered Health Services <br /> To be a Covered Health Service, the Health Service must be: <br /> A. Listed below as a Covered Health Service; <br /> B. Not listed below as an Exclusion; <br /> C. Medically Necessary; and <br /> D. Provided by, arranged by, or referred by a Participating <br /> Physician, except; <br /> 1. In the case of an Emergency; or <br /> 2. When a Member's Participating Physician, with prior written <br /> approval from the Plan, refers a Member to a <br /> non-participating Provider. <br /> 18 <br />