Every health plan has exclusions and limitations
— what the plans do not cover. General exclusions and limitations for
plans described in this brochure are listed here, along with additional
exclusions and limitations for the dental plans.
Additional exclusions and limitations for the medical plans are listed
in the enclosed brochures: PlanScape® for Individuals and Individual
and Family HMO Plans .
Please take a few moments to review these listings
and the listings in the PlanScape® and HMO brochures. We want you
to understand what your coverage does not include before you enroll.
These listings are an overview only. Plan-specific
Evidence of Coverage booklets contain a comprehensive list of each plan’s
exclusions and limitations. For a sample copy of an Evidence of Coverage
booklet, ask your agent or contact us.
Exclusions and Limitations Common to All Individual
Medical Plans
 Conditions
covered by workers’ compensation or similar laws.
Experimental
or investigative care or therapy.
Any services
provided by a local, state, county or federal government agency, including
any foreign government.
Services or
supplies not specifically listed as covered under the plan agreement.
Services received
before your Effective Date or during an inpatient stay that began before
your Effective Date.
Services rendered
before coverage begins or after coverage ends.
Services or
supplies for which no charge is made, or for which no charge would be
made if you had no insurance coverage or services for which you are
not legally obligated to pay.
Services provided
by relatives, and professional services received from a person who lives
in your home or who is related to you by blood, marriage or adoption.
Any services
to the extent you are entitled to receive Medicare benefits for those
services without payment of additional premium for Medicare coverage.
For parts of Medicare requiring additional premium payment, services
are excluded for those parts of Medicare the member has enrolled in.
Routine physical
exams, except for preventive care services (e.g., physical exams for
insurance, employment, licenses or school are not covered). Except as
specifically stated for PPO Share 500/1000 plans.
Any amounts
in excess of the maximum amounts stated in the Maximum Comprehensive
and Copayment/Coinsurance Lists sections of your agreement.
Sex change
operations or related treatment and study.
Cosmetic surgery
or other services for beautification, including any complications arising
from or the result of cosmetic surgery, except for reconstructive surgery.*
Services primarily
for weight reduction or treatment of obesity, or any care which involves
weight reduction as the main method of treatment, except medically necessary
treatment of morbid obesity with our prior authorization.
Dental care
and treatment or treatment on or to the teeth and gums — unless covered
under accidental injury.
Dental implants.
Hearing aids.
Contraceptive
drugs or devices including Norplant and Norplant kits, except injectable
contraceptives when administered by a physician. (Contraceptives are
covered under all plans’ prescription benefits except the Basic Plan.)
All services
related to the evaluation or treatment of infertility, including all
tests, consultations, medications, surgical, medical or lab procedures,
and reversal of sterilization.
Private duty
nursing, including inpatient or outpatient services of a private duty
nurse.
Eyeglasses
or contact lenses unless specified in your plan agreement.
Certain eye
surgeries, including those solely for the purpose of correcting refractive
defects of the eye such as nearsightedness (myopia) and astigmatism,
and for farsightedness (presbyopia).
Diagnostic
admissions, including inpatient room and board charges in connection
with a hospital stay primarily for diagnostic tests that could have
been safely performed on an outpatient basis, and inpatient admissions
primarily for diagnostic studies when inpatient bed care is not medically
necessary.
Mental and
nervous disorders, substance abuse, and learning disabilities, except
as specifically stated under the benefits sections of the plan agreement.
Orthopedic
shoes (except when joined to braces) or shoe inserts, except for limited
benefits as stated in the Evidence of Coverage.
Orthodontic
services, braces, and other orthodontic appliances.
No payment
will be made for services or supplies for the treatment of a preexisting
condition during a period of six months following your effective date.
This limitation does not apply to a child born or newly adopted by an
enrolled subscriber or spouse. Also, if you were covered under qualifying
prior coverage within 63 days of becoming covered under this Agreement,
the time spent under the qualifying prior coverage will be used to satisfy,
or partially satisfy, the six-month period.
Consultations
provided by telephone or facsimile machines.
Educational
services except as specifically provided or arranged by Blue Cross.
Nutritional
counseling and food supplements except as stated in your plan agreement.
No benefits
are provided for care and treatment furnished in a non-contracting hospital,
except for medical emergencies as specified in your agreement.
Items which
are furnished primarily for your personal comfort or convenience: air
purifiers, air conditioners, humidifiers, exercise equipment, treadmills,
spas, elevators and supplies for comfort, hygiene or beautification.
Custodial
care. Custodial care is care that does not require the services of trained
medical or health professionals, such as, but not limited to, help in
walking, getting in and out of bed, bathing, dressing, preparation and
feeding of special diets, and supervision of medications that are ordinarily
self-administered. Domiciliary, or rest cures for which facilities and/or
services of a general acute hospital are not medically required, including
resident treatment centers are also excluded.
* Does not apply to reconstructive surgery to restore
a bodily function or to correct a deformity caused by injury or medically
necessary reconstructive surgery performed to restore symmetry incident
to mastectomy.
Services furnished
through outdoor treatment programs.
Outpatient
speech therapy
Benefits
for Hospice services are limited to a lifetime maximum of $10,000 per
member for participating an non-participating providers combined (BC
Life PPO Share 5000, BC Life PPO Share 1000, BC Life PPO Share 5000,
PPO Saver, PPO Basic only).
Genetic testing
for non-medical reasons or when there is not a medical indication or
no family history of genetic abnormality.
Additional Exclusions and Limitations for Basic
PPO 1000/2500 Only
Maternity
care.
Preventive
benefits, except for Pap and PSA tests, and mammograms, not specifically
listed in the plan policy.
Outpatient
prescription drugs
Acupuncture/Acupressure
Physician
office visits and associated costs, except as specifically described
in the Certificate.
Physical or
occupational medicine or chiropractic services, except provided during
an inpatient hospital confinement.
Eye glasses
and eye examinations.
Additional Exclusions and Limitations for PPO Saver Only
Maternity
Care
Additional Exclusions and Limitations for Medical
HMO Plans Only
Care not authorized
by your Primary Care Physician at your participating medical group (PMG)
or IPA.
Growth hormone
treatment.
Amounts in
excess of customary and reasonable charges for out-of-area emergency
services.
Eyeglasses
or contact lenses unless specified in your plan agreement.
Acupuncture/Acupressure
Chiropractic
Services
Immunizations
for foreign travel not specifically listed as covered.
Treatment
for chronic alcoholism or other substance abuse unless specified in
the plan agreement.
Inpatient
mental care, including acute alcoholism and drug addiction benefits
except detoxification.
Treatment
of mental and nervous disorders except as stated in the plan agreement.
Rehabilitative
care except as stated in the plan agreement.
Private room,
unless specified in the plan agreement.
Reconstructive
surgery, purchase or replacement of artificial limbs or prosthesis unless
the medical condition creating the need for the limb or prosthesis occurred
while you were covered under the plan.
Medical, surgical
and/or psychological treatment of a sexual dysfunction except when a
sexual dysfunction is a result of a physical abnormality, defect or
disease.
Medical, surgical
services, supplies or treatment to the joint of the jaw (temporomandibular
joint), upper jaw (maxilla) or lower jaw (mandible), unless related
to a tumor or accident occurring while covered.
Routine physical
examinations or tests that do not directly treat an acute illness, injury
or condition unless authorized by your Primary Care Physician, except
in no event will any physical examination or test required by employment
or government authority, or at the request of a third party, such as
a school, camp or sports-affiliated organization, be covered unless
medically necessary.
Care or treatment
of a pregnancy, or any condition related to pregnancy (except treatment
of complications of pregnancy or Cesarean section deliveries) when conception
has occurred before the effective date of the plan agreement. However,
if you were covered under Creditable Coverage within 62 days of becoming
covered, the time spent under Creditable Coverage will be used to satisfy,
or partially satisfy the six (6) month period.
Exclusions and Limitations Common to All Individual
Dental Plans
Conditions
covered by workers’ compensation or similar laws.
Experimental
or investigative care or therapy (except for the Dental SelectHMO).
Any services
provided by a local, state, county or federal government agency including
any foreign government.
Services or
supplies not specifically listed as covered under the plan agreement.
Conditions
arising from any act of war, invasion, armed aggression or release of
nuclear energy.
Services received
before your Effective Date or during an inpatient stay that began before
your Effective Date.
Services rendered
before coverage begins or after coverage ends.
Services or
supplies for which no charge is made, or for which no charge would be
made if you had no insurance coverage or services for which you are
not legally obligated to pay.
Services provided
by relatives, and professional services received from a person who lives
in your home or who is related to you by blood, marriage or adoption.
Any services
to the extent that you are entitled to receive Medicare benefits for
those services, whether or not Medicare benefits are actually paid
Additional
Exclusions and Limitations for Dental PPO Plan Only:
Any amounts
in excess of the maximum amounts stated in the Benefit Schedule section.
Any services
performed for cosmetic purposes are not covered under this policy, unless
they are for correction of functional disorders or as a result of an
accidental injury occurring while you were covered under this policy.
Charges for
treatment by other than a licensed dentist or physician, except charges
for dental prophylaxis performed by a licensed dental hygienist, under
the supervision and direction of a dentist.
Replacement
of an existing prosthesis which has been lost or stolen; or which in
the opinion of the dentist is or can be made satisfactory.
Replacement
of a fixed or removable prosthesis for which benefits were paid by us,
if such replacement occurs within five years of the original placement,
unless the denture is a stayplate used during the healing period for
recently extracted anterior teeth.
Orthodontic
services, braces appliances and all related services.
Diagnosis
or treatment of the joint of the jaw and/or occlusion (the way upper
and lower teeth meet) services, supplies or appliances provided in connection
with:
Any treatment
to alter, correct, fix, improve, remove, replace, reposition, restore
or otherwise treat the joint of the jaw (temporomandibular joint) or
associated musculature, nerves and other tissues for any reason or by
any means.
Any treatment,
including crowns, caps and/or bridges to change the way the upper and
lower teeth meet (occlusion).
Treatment
to change vertical dimension (the space between the upper and lower
jaw) for any reason or by any means including the restoration of vertical
dimension because teeth have worn down.
Procedures
requiring appliances or restorations (other than those for replacement
of structure loss from caries) that are necessary to alter, restore
or maintain occlusions. These include but are not limited to:
Changing the
vertical dimension.
Replacing
or stabilizing lost tooth structure by attrition, abrasion, or erosion.
Realignment
of teeth.
Gnathological
recording (recording of the movement of the jaws for the purpose of
mounting functional models of the teeth).
Occlusal equilibration.
Periodontal
splinting.
Oral examinations,
including prophylaxis (teeth cleaning), exceeding two visits per year.
More than
one set of full-mouth x-rays or its equivalent in a three-year period.
Fluoride applications
and sealants for patients over 18 years of age. Fluoride applications
exceeding two visits per year.
Correction
of congenital or development malformation for a policyholder or dependent
including but not limited to cleft palate, maxillary or mandibular (upper
and lower jaw) malformations, enamel hypoplasia (lack of development),
fluorosis (a type of discoloration of the teeth), and anodontia (congenitally
missing teeth).
Adjustment,
repairs or relines to prostheses for a period of six months from initial
placement if the prostheses were paid for under this policy.
Fixed bridges,
removable cast partials and/or cast crowns with or without veneers and
inlays for patients under 16 years of age.
Replacement
of crowns and cast restorations including porcelain inlays and porcelain
crowns for which benefits were paid by BC Life, if such replacement
occurs within five years of the original placement.
If a policyholder
transfers from the care of one dentist to that of another dentist during
the course of treatment, or if more than one dentist renders services
for one dental procedure, BC Life shall be liable only for the amount
it would have been liable for had one dentist rendered the services.
Prescribed
drugs, pre-medication or analgesia (relief of pain).
Oral hygiene instruction.
Services for treatment of malignancies
and neoplasms are not covered dental benefits.
All hospital costs and any
additional fees charged by the dentist for hospital treatment.
Implants (materials implanted
into or on bone or soft tissue), or the removal of implants are not
benefits under this policy. However, if implants are provided in association
with a covered prosthetic appliance, BC Life will allow the benefit
for a standard complete or partial denture or a bridge toward the cost
of implants and the prosthetic appliances.
Replacement of teeth missing
prior to the effective date of coverage with partial dentures, complete
dentures, or fixed bridges. Additional Exclusions and Limitations for
Blue Cross Dental SelectHMO Plans Only:Unless an exception is specifically
authorized by Blue Cross in writing, dental services must be received
from the member’s participating dental office or participating specialty
office.
No benefits
are provided for hospital or associated physician charges for any dental
treatment that cannot be performed in the participating dental office.
Prescription
drugs are not covered.
Treatment
of fractures or dislocations.
Dental treatment
or expenses incurred or in connection with any dental procedure started
prior to the member’s effective date.
Any treatment to correct a dental condition that resulted
from dental services performed by a non-participating dentist while
this coverage is in effect, and any dental services started by a non-
participating dentist will not be the responsibility of the participating
dental office or Blue Cross for completion.Histopathological exams,
and/or the removal of tumors, cysts, neoplasms, and foreign bodies not
covered under the medical plan.
A dental treatment plan which in the opinion of the
participating dentist and/or Blue Cross is not dentally necessary for
dental health or will not produce beneficial results.Teeth with questionable,
guarded or poor prognosis are not covered for endodontic treatment,
periodontal surgery or crowns and bridges. Plan will allow for observation
or extraction and prosthetic replacement.Gold, porcelain or resin fillings
on primary teeth are excluded.Services received after the benefit limit
under this agreement is reached.Orthodontic services must be received
from a participating orthodontic office.
In the event of a member’s loss of coverage, for any
reason, and at the time of loss of coverage, the member is still receiving
orthodontic treatment, the member will be responsible for the remainder
of the cost for that treatment at the participating orthodontist’s usual
and customary fee, prorated.Replacement of lost or stolen orthodontic
appliances or repair of orthodontic appliances broken due to negligence
of the member may not be discounted.
Myofunctional therapy and related services.Surgical
procedures incidental to orthodontic treatment, including but not limited
to extraction of teeth, solely for orthodontic reasons, exposure of
impacted teeth, correction of micrognathia or macrognathia, or repair
of cleft palate.Treatment of orthodontic cases begun prior to the member’s
effective date of eligibility or after the termination of eligibility
of coverage.Changes in treatment necessitated by an accident of any
kind.Treatment related to the joint of the jaw (temporomandibular joint,
TMJ) and/or hormonal imbalance.
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