These exclusions apply to the medical plans only (including chemical dependency/mental health, complementary care, and vision) and do not apply to the wellness programs, dental options and EAP.

Preventive Care

Preventive services and immunizations are covered according to guidelines set forth by the United States Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA).

Waiting Periods

No benefits are provided for treatment relating to a transplant until the member has been covered under this or a prior plan for 24 consecutive months. There is a six-month waiting period that must be met prior to benefits being available for pre-existing conditions. Members may receive credit from prior medical coverage. Pre-existing condition waiting periods do not apply to Members up to age 19.

Outside the Service Area

Members have the security of knowing they can access Blue Cross and/or Blue Shield (Blue Plan) providers across the country and worldwide through the BlueCard® Program. Plan benefits apply as described above, and members may receive discounts on their services.

General Medical Exclusions

Coverage is not provided for any of the following, including direct complications or consequences that arise from:

• Cosmetic/Reconstructive Services and Supplies except for reconstruction for functional injury and disease, to treat a congenital anomaly for members up to age 18, and for breast reconstruction following a medically necessary mastectomy to the extent required by law
• Counseling in the absence of illness
• Custodial Care: Non-skilled care and helping with activities of daily living
• Dental Examinations and Treatments
• Fees, Taxes, Interest: Charges for shipping and handling, postage, interest, or finance charges that a provider might bill
• Government Programs: Benefits that are covered, or would be covered in the absence of this plan, by any federal, state or governmental program
• Infertility except to the extent covered services are required to diagnose such condition
• Investigational Services: Treatment or procedures (health interventions) and services, supplies, and accommodations provided in connection with investigational treatments or procedures
• Medications without a Prescription Order
• Military Service Related Conditions: The treatment of any condition caused by or arising out of a member’s active participation in a war or insurrection or conditions incurred in or aggravated during performance in the Uniformed Services
• Motor Vehicle Coverage and Other Insurance Liability
• Non-Direct Patient Care including appointments scheduled and not kept, charges for preparing medical reports, itemized bills or claim forms, and visits or consultations that are not in person, including telephone consultations and email exchanges
• Non-Duplication of Medicare: Services and supplies to the extent payable under Medicare, when by law, the plan would not be primary to Medicare had the member properly enrolled in Medicare when first eligible regardless of whether or not the member actually enrolled
• Obesity or Weight Reduction/Control: Medical treatment, medication, surgical treatment (including reversals), programs, or supplies that are intended to result in or relate to weight reduction, regardless of diagnosis
• Orthognathic Surgery except for congenital conditions, temporomandibular joint disorder, injury, and sleep apnea
• Personal Comfort Items: Items that are primarily for comfort, convenience, cosmetics, environmental control, or education
• Physical Exercise Programs and Equipment including hot tubs or membership fees at spas, health clubs, or other facilities; applies even if the program, equipment, or membership is recommended by the member’s provider
• Private Duty Nursing including ongoing shift care in the home
• Riot, Rebellion and Illegal Acts: Services and supplies for treatment of an illness, injury, or condition caused by a member’s voluntary participation in a riot, armed invasion or aggression, insurrection, or rebellion or sustained by a member while committing an illegal act or felony
• Routine Foot Care including treatment of corns and calluses and trimming of nails
• Routine Hearing Exams
• Self-Help, Self-Care, Training, or Instructional Programs including childbirth classes, diet and weight monitoring services and instruction programs, including those programs that teach a person how to use durable medical equipment or how to care for a family member
• Services and Supplies Provided by a Member of Your Family
• Services and Supplies That Are Not Medically Necessary
• Services to Alter Refractive Character of the Eye
• Sexual Reassignment Treatment and Surgery: Treatment, surgery, and counseling services for sexual reassignment
• Sexual Dysfunction: Regardless of cause, except for counseling provided by covered, licensed mental health practitioners
• Third-Party Liability: Services and supplies for treatment of illness or injury for which a third party is or may be responsible
• Travel and Transportation Expenses other than covered ambulance services

• Work-Related Conditions except for subscribers who are owners, partners, or corporate officers and are exempt from state or federal workers’ compensation law

This is a brief summary of benefits; it is not a certificate of coverage. All benefits must be medically necessary. For full coverage provisions, refer to the contract.