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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
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Conditions covered by workers’ compensation or similar laws.
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Experimental or investigative care or therapy.
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Any services provided by a local, state, county or federal
government agency, including any foreign government.
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Services or supplies not specifically listed as covered under the
plan agreement.
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Services received before your Effective Date or during an
inpatient stay that began before your Effective Date.
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Services rendered before coverage begins or after coverage ends.
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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.
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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.
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Services or supplies that are not medically necessary, as
determined by Blue Cross of California or BC Life & Health.
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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.
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Any amounts in excess of the maximum amounts stated in the
Maximum Comprehensive and Copayment/Coinsurance Lists sections of
your agreement.
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Sex change operations or related treatment and study.
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Cosmetic surgery or other services for beautification, including
any complications arising from or the result of cosmetic surgery,
except for reconstructive surgery.*
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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.
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Dental care and treatment or treatment on or to the teeth and
gums — unless covered under accidental injury.
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Dental implants.
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Hearing aids.
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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.)
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All services related to the evaluation or treatment of
infertility, including all tests, consultations, medications,
surgical, medical or lab procedures, and reversal of sterilization.
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Private duty nursing, including inpatient or outpatient services
of a private duty nurse.
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Eyeglasses or contact lenses unless specified in your plan
agreement.
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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).
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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.
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Mental and nervous disorders, substance abuse, and learning
disabilities, except as specifically stated under the benefits
sections of the plan agreement.
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Orthopedic shoes (except when joined to braces) or shoe inserts,
except for limited benefits as stated in the Evidence of Coverage.
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Orthodontic services, braces, and other orthodontic appliances.
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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.
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Consultations provided by telephone or facsimile machines.
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Educational services except as specifically provided or arranged
by Blue Cross.
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Nutritional counseling and food supplements except as stated in
your plan agreement.
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No benefits are provided for care and treatment furnished in a
non-contracting hospital, except for medical emergencies as
specified in your agreement.
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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.
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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.
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* 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
Additional Exclusions and Limitations for PPO
Saver Only
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Maternity Care
Additional Exclusions and Limitations for Medical
HMO Plans Only
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Care not authorized by your Primary Care Physician at your
participating medical group (PMG) or IPA.
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Growth hormone treatment.
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Amounts in excess of customary and reasonable charges for
out-of-area emergency services.
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Eyeglasses or contact lenses unless specified in your plan
agreement.
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Acupuncture/Acupressure
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Chiropractic Services
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Immunizations for foreign travel not specifically listed as
covered.
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Treatment for chronic alcoholism or other substance abuse unless
specified in the plan agreement.
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Inpatient mental care, including acute alcoholism and drug
addiction benefits except detoxification.
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Treatment of mental and nervous disorders except as stated in the
plan agreement.
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Rehabilitative care except as stated in the plan agreement.
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Private room, unless specified in the plan agreement.
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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.
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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.
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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.
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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.
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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:
Additional Exclusions and Limitations for Dental
PPO Plan Only:
— 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.
— 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.
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Oral examinations, including prophylaxis (teeth cleaning),
exceeding two visits per year.
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More than one set of full-mouth x-rays or its equivalent in a
three-year period.
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Fluoride applications and sealants for patients over 18 years of
age. Fluoride applications exceeding two visits per year.
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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).
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Adjustment, repairs or relines to prostheses for a period of six
months from initial placement if the prostheses were paid for under
this policy.
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Fixed bridges, removable cast partials and/or cast crowns with or
without veneers and inlays for patients under 16 years of age.
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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.
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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.
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Prescribed drugs, pre-medication or analgesia (relief of pain).
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Oral hygiene instruction.
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Services for treatment of malignancies and neoplasms are not
covered dental benefits.
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All hospital costs and any additional fees charged by the dentist
for hospital treatment.
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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.
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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:
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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.
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No benefits are provided for hospital or associated physician
charges for any dental treatment that cannot be performed in the
participating dental office.
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Prescription drugs are not covered.
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Treatment of fractures or dislocations.
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Dental treatment or expenses incurred or in connection with any
dental procedure started prior to the member’s effective date.
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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.
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Histopathological exams, and/or the removal of tumors, cysts,
neoplasms, and foreign bodies not covered under the medical plan.
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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.
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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.
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Gold, porcelain or resin fillings on primary teeth are excluded.
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Services received after the benefit limit under this agreement is
reached.
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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.
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Replacement of lost or stolen orthodontic appliances or repair of
orthodontic appliances broken due to negligence of the member
may not be discounted.
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Myofunctional therapy and related services.
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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.
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Treatment of orthodontic cases begun prior to the member’s
effective date of eligibility or after the termination of
eligibility of coverage.
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Changes in treatment necessitated by an accident of any kind.
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Treatment related to the joint of the jaw (temporomandibular
joint, TMJ) and/or hormonal imbalance.
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Blue Cross Plan Scape
