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This is a representative listing of major exclusions and limitations. An extra detailed listing can be found in the Combined Evidence of Coverage and Disclosure Form/Certificate.
Exclusions and Limitations
Common to All Medical Plans:
- Any amounts in excess of the maximum amounts as stated in
the Combined Evidence of Coverage and Disclosure Form/Certificate.
- Services or supplies determined by Blue Cross not to be
medically necessary.
- Services received before your effective date.
- Services received after your coverage ends.
- Any conditions for which benefits are recovered or can be
recovered either by adjudication, settlement or otherwise,
under any workers' compensation, employer's liability law
or occupational disease law, even if you do not claim those
benefits.
- Services for which you are not legally obligated to pay
for or services which no charge is made to you in the absence
of insurance coverage.
- Services not specifically listed in the Combined Evidence
of Coverage and Disclosure Form/Certificate as covered services.
- Professional services received from a person who lives in
the member's home or who is related to the member by blood,
marriage or adoption.
- Optometric services, eye exercises including orthoptics,
eyeglasses, contact lenses and eye refractions, except as
specifically stated in the Combined Evidence of Coverage and
Disclosure Form/Certificate.
- Eye surgeries performed solely for the purpose of correcting
refractive defects such as near-sightedness (myopia), astigmatism
and far-sightedness (presbyopia).
- Hearing aids
- 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 Blue Cross prior authorization.
- Sterilization reversal and any other services for infertility
except as specifically stated in the Combined Evidence of
Coverage and Disclosure Form/Certificate. Any amounts in excess
of the lifetime maximum for infertility services.
- Procedures or treatments to change characteristics of the
body to those of the opposite sex. This includes any medical,
surgical or psychiatric treatment or study related to sex
changes.
- All dental services, including diagnostic, preventative,
x-rays, dentures, bridges, crowns, caps, orthodontic services,
braces and other orthodontic appliances and supplies, dental
implants and related procedures, except as specifically stated
in the Combined Evidence of Coverage and Disclosure Form/Certificate.
- Cosmetic surgery or other services that are performed to
alter or reshape normal structures of the body in order to
improve appearance.
- Routine physical examinations for insurance, employment,
license or school.
- Treatment of mental or nervous disorders (including nicotine
use) or psychological testing except as specifically stated
under the benefits section of the Combined Evidence of Coverage
and Disclosure Form/Certificate.
- Custodial care.
- Services which are experimental or investigational in nature.
- Educational services, except as specifically provided or
arranged by Blue Cross.
- Nutritional counseling, except as specifically provided
or arranged by Blue Cross.
- Services provided by a local, state or federal government
agency, except when payment is expressly required by federal
or state law.
- Conditions caused by an act of war or the inadvertent release
of nuclear energy when government funds are available for
treatment of illness or injury arising from such release of
nuclear energy.
- Inpatient room and board charges in connection with a hospital
stay primarily for diagnostic tests which could have been
performed safely on an outpatient basis.
- Contraceptive devices unless your physician determines that
oral contraceptive drugs are not medically appropriate
- Consultations provided by telephone or facsimile machines.
- Items which are furnished primarily for personal comfort
or convenience including, but not limited to air purifiers,
air conditioners, humidifiers, exercise equipment, treadmills,
shoes, spas, elevators, hair pieces, diapers and supplies
for hygiene or beautification.
- Services or supplies furnished and billed by a provider
outside the U.S., unless for medical emergencies.
- All durable medical equipment used for infusion therapy.
- Health club memberships.
- Services for which you are entitled to receive Medicare
benefits, whether or not they are actually paid.
- Charges in excess of the limited fee schedule and reasonable
and customary amounts determined by Blue Cross.
- Food supplements for formulas and special food products
that are prescribed by a physician in consultation with a
metabolic disease specialist if it is deemed medically necessary
to prevent complications of phenylketonuria (PKU).
Additional Exclusion
and Limitations Applicable only to the No deductible Co pay Plans:
- Inpatient or outpatient services of a private duty nurse,
except as specifically stated under the benefits section of
the Combined Evidence of Coverage and Disclosure Form.
- Preexisting conditions, except as specifically stated in
the Combined Evidence of Coverage and Disclosure Form.
- Care and treatment furnished in a non-contracting hospital,
except for medical emergencies.
- Routine hearing exams, except as specifically listed in
the Combined Evidence of Coverage and Disclosure Form.
- Routine physical exams, except as specifically stated in
the Combined Evidence of Coverage and Disclosure Form.
Additional Exclusions
and Limitations Applicable only to the HMO Plans:
- Care not authorized by your PMG or IPA.
- Amounts in excess of customary and reasonable charges for
care rendered by a non-participating provider without a referral
from your PMG or IPA.
- Routine immunizations and immunizations for foreign travel.
- Rehabilitative care, such as physical therapy, occupational
therapy and speech therapy, unless provided by a Home Health
Agency, a visiting Nurse Association, or except as specifically
stated in the Combined Evidence of Coverage and Disclosure
Form.
- Conditions of the jaw or teeth secondary to malocclusion
or orthognathic conditions.
- Growth hormone treatment.
- Acupuncture/acupressure.
Additional Exclusions
and Limitations Applicable only to the Basic PPO Plan:
- Physician office visits and associated costs, except Well
Baby and Preventative Care services as described in the Certificate.
- Inpatient or outpatient services of a private duty nurse,
except as specifically stated in the Certificate.
- Outpatient drugs, medications or other substances dispensed
or administered in any outpatient setting.
- Physical or occupational medicine or chiropractic services,
except when provided during an inpatient hospital confinement.
- Outpatient speech therapy.
- Care and treatment furnished in a non-contracting hospital
except for medical emergencies.
- Routine hearing exams except as specifically stated in the
Certificate.
Additional Exclusions
and Limitations Applicable only to the High Deductible EPO Plan:
- Services from a non-participating provider except as specifically
stated in the benefits section of the Combined Evidence of
Coverage and Disclosure Form.
- Inpatient or outpatient services of a private duty nurse,
except as specifically stated in the benefits section of the
Combined Evidence of Coverage and Disclosure Form.
- Care and treatment furnished in a non-contracting hospital
or ambulatory surgical center except for medical emergencies.
- Routine hearing exams, except as specifically listed in
the Combined Evidence of Coverage and Disclosure Form.
- Routine physical exams, except as specifically listed in
the Combined Evidence of Coverage and Disclosure Form.
Additional Exclusion
and Limitations Applicable only to the Saver PPO Plan:
- Physician office visits and associated costs, except as
specifically described in the Certificate.
- Inpatient or outpatient services of a private duty nurse,
except as specifically described in the Certificate.
- Physical or occupational medicine or chiropractic services,
except provided during an inpatient hospital confinement.
- Outpatient speech therapy
- Care and treatment furnished in a non-contracting hospital,
except for medical emergencies.
- Outpatient drugs, medications or other substances dispensed
or administered in any outpatient setting in excess of the
maximum amount stated in Certificate.
Exclusions and Limitations
Common to All Dental Plans:
- Services or supplies determined by Blue Cross not to be
medically necessary.
- Services received before your effective date or after your
coverage ends.
- Services for which you are not legally obligated to pay
or for services which no charge is made to you in the absence
of insurance coverage.
- Any conditions for which benefits are recovered or can be
recovered either by adjudication, settlement or otherwise,
under any workers' compensation, employer's liability law
or occupational disease law, even if you do not claim those
benefits.
- Conditions caused by an act of war or the inadvertent release
of nuclear energy when government funds are available for
treatment of illness or injury arising from such release of
nuclear energy.
- Services provided by a local, state or federal government
agency, except when payment is expressly required by federal
or state law.
- Any services to the extent that you are entitled to receive
Medicare benefits for those services, whether or not Medicare
benefits are actually paid.
- Services for cysts and neoplasm.
- All hospital costs and any additional fees charged by the
dentist for hospital treatment.
- Professional services received from a person who lives in
the insured's home or who is related to the member by blood,
marriage or adoption.
- Prescription drugs.
- 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.
- Gold, porcelain or resin fillings on primary teeth.
Exclusions and Limitations
Common to all PPO/FFS Dental Plans:
- Diagnosis or treatment of the joint of the jaw and/or occlusion
(the way the 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.
- Oral examinations exceeding two visits per year.
- Prophylaxis (teeth cleaning) exceeding two (2) treatments
per year.
- Any services performed for cosmetic purposes including,
but not limited to, bleaching of non-vital discolored teeth
& bonding procedures.
- Any procedure not specifically listed as a covered service.
- Any amounts in excess of the maximum amounts stated in the
"Maximum Benefits" section of the Certificate.
- 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 if such replacement
occurs within five years of the original placement, unless
the prosthesis is a stay plate used during the healing period
for recently extracted anterior teeth. Initial placement of
prosthetics if teeth being replaced have been missing before
insured was covered by the Plan.
- Diagnosis or treatment of the joint of the jaw and/or occlusion
(the way the 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 or other tissues for any reason or by any means;
or
- Any treatment, including crowns, caps and/or bridges to
change the way the upper and lower teeth meet (occlusion);
or
- 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 structural 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
- Occlusal equilibration
- Splinting
- Services not included as a covered procedure, unless they
are similar in nature to an included procedure; in such event
the benefit payable will be based on the most nearly comparable
services included.
- Services or supplies that are considered experimental or
investigational in nature.
- More than one set of full-mouth x-rays or a panarex in a
three-year period.
- Fluoride applications are limited to once per year up to
the age of 18.
- Dental treatment or expenses incurred in connection with
the correction of congenital or developmental malformation.
- Adjustment, repairs, or relines of prostheses for a period
of six months from the initial placement if the prostheses
were paid for under the Certificate.
- Inlays, onlays, crowns, fixed bridges or removable cast
partials for patients under sixteen (16) years of age. Space
maintainers for Insurers over sixteen (16) years of age.
- If an insured transfers from the care of one dentist to
another dentist during the course of treatment, or if more
than one dentist renders services for one dental procedure,
BC Life & Health 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.
- Oral hygiene instruction.
- Materials implanted into or on bone or soft tissue and all
adjunctive services (including, but not limited to, surgery,
cleaning, etc.) performed in conjunction with the placement
or removal of implants.
- Replacement of teeth missing prior to the effective date
of coverage with partial dentures, complete dentures or fixed
bridges.
- Services on teeth that appear to have a poor prognosis,
or that are not reasonably necessary or customarily performed
are not covered.
- If multiple endodontic treatments are necessary on the same
tooth within a period of one year, the allowance will be made
for only one procedure.
- The extraction of immature erupting third molars and non
pathologic, a symptomatic third molar extractions is excluded.
- Temporary services are considered an integral part of the
final services rather than a separate service, and are therefore
not eligible for benefits.
- Sealants are limited to one treatment every 36 months per
tooth for children 15 years of age for permanent first and
second molars, un restored.
- Periodontal scaling and root planning will be limited to
once quadrant per 24 months. Polishing of all teeth is considered
part of this treatment.
- Osseous and mucogingival surgery will be limited to once
per quadrant per 36 months.
- Gross debridement allowed one time at the beginning of a
periodontal treatment plan. Subsequent requirement for debridement
is considered patient neglect and would be the financial responsibility
of the insured.
- Precision attachments, characterization or personalization
of dentures if excluded.
- Ligation and crown lengthening are not covered.
Additional Exclusions and
Limitations Specific to the Standard Option PPO and FFS Dental
Plans:
- Braces, appliances and all related orthodontic services.
Additional Exclusions
and Limitations Specific to the Basic Option PPO and FFS Dental
Plans:
- Braces, appliances and all related orthodontic services.
Additional Exclusions
and Limitations Specific to the High Option PPO and FFS Dental
Plans:
- Orthodontic services: These orthodontic exclusions and limitations
are in addition to the basic dental plan exclusions and limitations:
- Treatment of orthodontic cases begun prior to the Insured's
Effective Date of coverage or after the termination of eligibility
for coverage.
- Myofunctional therapy and related services. (Myofunctional
therapy involves the use of muscle exercises as an adjunct
to orthodontic mechanical correction or malocclusion.)
- 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 related to temporomandibular joint (jaw joint)
disturbances and/or hormonal imbalance.
- Orthodontic records, including, but not limited to, cephalometric
tracing, photographs, study models and diagnostic radiographs.
- Replacement of lost or stolen orthodontic appliances or
repair of orthodontic appliances broken due to negligence
of the insured.
- Any orthopedic/orthodontic treatment which may be deemed
advantageous or necessary by the orthodontist prior to the
24 months of standard active treatment. Orthodontic treatment
for malocclusions, which, in the opinion of the orthodontist
will not produce beneficial results.
- Orthodontic treatment in conjunction with oral surgical
procedures, including but not limited to orthognathic surgery.
- Changes in treatment necessitated by an accident of any
kind.
- The retreatment of a previously treated orthodontic case
is not covered.
- Special orthodontic appliances including but not limited
to lingual or invisible braces, sapphire or clear braces,
or ceramic braces are considered cosmetic and not included
as covered benefits under the Certificate.
Exclusions and Limitations
Common to All HMO Dental Plans:
- Dental services must be received from the member's participating
dental office unless an exception is specifically authorized
by the member's selected participating dental office and/or
Blue Cross in writing.
- Any amounts in excess of the maximum amounts stated in the
combined evidences of coverage and the disclosure form.
- 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.
- Treatment of fractures or dislocations.
- Histopathological exams, and/or removal of tumors, cysts,
neoplasms and foreign bodies.
- Teeth with questionable, guarded or poor prognosis are not
covered for endodontic, periodontal surgery, or crown and
bridge.
- Orthodontic Exclusions and Limitations:
- 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 during the treatment period,
the member and NOT Blue Cross will be responsible for the
remainder of the cost for that treatment, at the participating
orthodontist's usual and customary fee, prorated for the
number of months of treatment remaining.
- Myofunctional therapy and related services.
- Replacement of lost or stolen orthodontic appliances or
repair of orthodontic appliances broken due to negligence
of the member.
- 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 for 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.
Additional Exclusions
and Limitations Specific to the DentalNet Plan:
- Treatment of the joint of the jaw and/or occlusion (the
way the 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.
- Oral examinations including prophylaxis (teeth cleaning)
exceeding two visits per year.
- Any services performed for cosmetic purposes, (including,
but not limited to, bleaching for non-vital discolored teeth
and bonding procedures).
- Services that are considered experimental or investigative
in nature.
- Any procedure not specifically listed as a covered service.
- Periodontal scaling and root planing and/or gingival curettage
are limited to one course of therapy per quadrant per year.
- Partial dentures are not eligible for replacement within
five years of original placement unless required as a result
of additional tooth loss which cannot be restored by modification
of the existing partial denture. Crowns, bridges, inlays and/or
complete dentures are not eligible for replacement within
five years of original placement.
- For crowns, nonremovable bridges and periodontal surgery,
the member must meet the six-month waiting period described
in the Exclusions and Limitations section of the Evidence
of Coverage before any of these services are covered.
- Complete and/or partial dental relines are limited to one
per denture in a 12-month period.
- In cases where multiple acceptable methods of treatment
exist, the least expensive professionally acceptable treatment
is considered the covered benefit.
- The use of alloys with 25 percent or more noble metal content
for any restorative procedure is considered optional and if
used, the additional cost for such alloy is the member's responsibility.
- Removal of impacted teeth is limited to impactions which
show radiographic evidence of pathologic condition or for
which the experiences symptoms of infection, swelling or chronic
pain.
- Pediatric dental specialist services are limited to $500.00
per year for each child. Charges in excess of $500.00 will
be your financial responsibility.
- For active orthodontic treatment extending beyond the 24-month
period, but before the retention phase begins, the member
will be required to pay the participating orthodontist up
to $55 for each additional month of active treatment.
- Retention services include initial fabrication, placement,
observation and adjustment of passive retention appliances
for a 12-month period. The retention services fee of $250is
the member's responsibility and payable at the beginning of
the retention phase of treatment. Retention service fees are
subject to review and modification on an annual basis.
- Dental services necessary solely for cosmetic reasons, including
but not limited to, bleaching of discolored teeth and bonding
procedures.
- Coverage for any dental treatment which, because of the
member's general health, or mental, emotional, behavioral
or physical limitations cannot be performed in the participating
dental office.
- 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.
- Dental treatment or expenses incurred in connection with
the correction of congenital or developmental malformations.
- Tooth implantation or transplantation, orthognathic surgery,
soft tissue or osseous grafts, hemisection, root amputation,
apexification, alveoloplasty, vestibuloplasty or ostectomy
procedures.
- Space maintainers, inlays, onlays, crowns, fixed bridges
or removable cast partials for members under sixteen years
of age.
- Materials implanted into or on bone or soft tissue and all
adjunctive services (including, but not limited to, surgery,
prosthesis, cleanings, etc.) performed in conjunction with
the placement or removal of implants.
- Dental treatment or procedures requiring or associated with
fixed prosthodontic restorations (other than for replacement
of structure loss from dental decay) required in conjunction
with altering vertical dimension, replacing tooth structure
lost by attrition, erosion or abrasion.
- Dental treatment or expenses incurred in connection with
periodontal splinting.
- General anesthesia, inhalation sedation, intravenous sedation
or intramuscular sedation.
- Porcelain or composite labial veneers for fixed prosthodontics,
posterior to the second bicuspid and composite fillings posterior
to the cuspid.
- A member must be enrolled for a period of six (6) consecutive
months under the Evidence of Coverage to be eligible for benefits
for services related to surgical periodontics and fixed prosthodontics
or individual crown restorations.
- The re-treatment of a previously treated orthodontic case.
- Orthodontic records including but not limited to cephalometric
tracings, photographs, study models and diagnostic radiographs.
- Any orthopedic/orthodontic treatment which may be deemed
advantageous or necessary by the participating orthodontist
prior to the 24 months of standard active treatment.
- Orthodontic appliances including but not limited to braces,
sapphires or clear braces, or ceramic braces.
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