Section 6. General Exclusions - Services, Drugs, and Supplies We Do Not Cover

2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover

Section 6. General Exclusions – Services, Drugs, and Supplies We Do Not Cover

The exclusions in this Section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3, You need prior Plan approval for certain services.

We do not cover the following:

Services, drugs, or supplies you receive while you are not enrolled in this Plan.
Services, drugs, or supplies that are not medically necessary.
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice in the United States.
Services, drugs, or supplies billed by Preferred and Member facilities for inpatient care related to specific medical errors and hospital-acquired conditions known as Never Events (see definition on page 155).
Experimental or investigational procedures, treatments, drugs, or devices (see Section 5(b) regarding transplants).
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
Services, drugs, or supplies related to sexual dysfunction or sexual inadequacy (except for surgical placement of penile prostheses to treat erectile dysfunction and gender affirming surgeries specifically listed as covered).
Travel expenses except as specifically provided for covered transplants performed in a Blue Distinction Center for Transplant (see page 76).
Services, drugs, or supplies you receive from a provider or facility barred or suspended from the FEHB Program.
Services, drugs, or supplies you receive in a country sanctioned by the Office of Foreign Assets Control (OFAC) of the U.S. Department of the Treasury, from a provider or facility not appropriately licensed to deliver care in that country.
Services or supplies for which no charge would be made if the covered individual had no health insurance coverage.
Services, drugs, or supplies you receive without charge while in active military service.
Charges which the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/or B (see page 149), doctor’s charges exceeding the amount specified by the Department of Health & Human Services when benefits are payable under Medicare (limiting charge, see page 150), or state premium taxes however applied.
Prescriptions, services or supplies ordered, performed, or furnished by you or your immediate relatives or household members, such as spouse, parents, children, brothers, or sisters by blood, marriage, or adoption.
Services or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs; oxygen; and physical, speech, and occupational therapy provided by a qualified professional therapist on an outpatient basis are covered subject to Plan limits.
Services, drugs, or supplies you receive from noncovered providers.
Services, drugs, or supplies you receive for cosmetic purposes.
Services or supplies for the treatment of obesity, weight reduction, or dietary control, except for office visits, diagnostic tests, prior approved weight loss drugs covered under the pharmacy program, and procedures and services for the treatment of morbid obesity listed on page 65.
Services you receive from a provider that are outside the scope of the provider’s licensure or certification.
Any dental or oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or continued use of dentures, except as specifically described in Section 5(g), Dental Benefits, and Section 5(b) under Oral and Maxillofacial Surgery.
Orthodontic care for malposition of the bones of the jaw or for temporomandibular joint (TMJ) syndrome.
Services of standby physicians.
Self-care or self-help training.
Custodial or long-term care (see Definitions).
Personal comfort items such as beauty and barber services, radio, television, or phone.
Furniture (other than medically necessary durable medical equipment) such as commercial beds, mattresses, chairs.
Routine services, such as periodic physical examinations; screening examinations; immunizations; and services or tests not related to a specific diagnosis, illness, injury, set of symptoms, or maternity care, except for those preventive services specifically covered under Preventive Care, Adult and Preventive Care, Child in Sections 5(a) and 5(c), the preventive screenings specifically listed on pages 42-46 and page 85; and certain routine services associated with covered clinical trials (see page 145).
Recreational or educational therapy, and any related diagnostic testing, except as provided by a hospital during a covered inpatient stay.
Applied behavior analysis (ABA) and related services for any condition other than an autism spectrum disorder.
Applied behavior analysis (ABA) services and related services performed as part of an educational program; or provided in or by a school/educational setting; or provided as a replacement for services that are the responsibility of the educational system.
Topical Hyperbaric Oxygen Therapy (THBO).
Research costs (costs related to conducting a clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes).
Professional charges for after-hours care, except when associated with services provided in a physician's office.
Incontinence products such as incontinence garments (including adult or infant diapers, briefs, and underwear), incontinence pads/liners, bed pads, or disposable washcloths.
Alternative medicine services including, but not limited to, botanical medicine, aromatherapy, herbal/nutritional supplements (see page 118), meditation techniques, relaxation techniques, movement therapies, and energy therapies.
Services, drugs, or supplies related to medical marijuana.
Advanced care planning, except when provided as part of a covered hospice care treatment plan (see page 90).
Membership or concierge service fees charged by a healthcare provider.
Fees associated with copies, forwarding or mailing of records except as specifically described in Section 8.
Services not specifically listed as covered.
Services or supplies we are prohibited from covering under the Federal Law.