• Services or supplies which are not medically necessary or any experimental/investigational services or supplies.

• Charges resulting from the failure to keep a scheduled visit with a physician or other professional provider, for completion of any insurance forms, or for acquisition of medical records.

• Vision services or supplies, including but not limited to, orthoptics, vision training, vision therapy, radial keratotomy, contact lenses, eyeglasses or the fitting of contact lenses, photoreflective keratotomy, and LASIK.

• Cosmetic, reconstructive, or plastic surgery except as provided for on page 12 of the benefits booklet.

• General dental services.

• Any items of medical /surgical expense incurred for dental care and treatment, dental surgery, or dental appliances except unless medically necessary.

• Services or supplies for routine foot care, including shoe orthotics, insoles, or shoe inserts of any type (except when prescribed for a diagnosis of, or related to, diabetes).

• Services or supplies provided for obesity or weight reduction, except for medically necessary treatment of morbid obesity as determined by BCBSTX.

• Services or supplies provided for injuries sustained as a result of war, declared or undeclared, or any act of war or while on active or reserve duty in the armed forces of any country or international authority.

• Services or supplies provided for treatment or related services to the temporomandibular joint (TMJ), except for medically necessary diagnostic/surgical treatment.

• Any services or supplies provided in connection with an occupational sickness or an injury sustained in the scope of and in the course of any employment whether or not benefits are or could be, provided under Workers' Compensation.

• Items for patient convenience or comfort as determined by BCBSTX.

• Dietary and nutritional services (except for an inpatient nutritional assessment program provided in and by a hospital and approved by BCBSTX, or diabetic management services that are provided by a physician and approved by BCBSTX).

• Any services or supplies provided before the participant's effective date or after the expiration date of coverage.

• Charges that would not be made if you did not have health insurance or charges that you are not legally required to pay.

• Services or supplies provided by a person, entity, facility or hospital that has not been approved as a network or non-network provider by BCBSTX.

• Room and board charges during a hospital admission for diagnostic or evaluative procedures, unless BCBSTX determines that inpatient status is medically necessary.

• Marriage and family therapy/counseling, self-therapy, or therapy as a part of training.

• Travel services and accommodations, whether or not recommended or prescribed, except ambulance services.

• Any services or supplies provided for, in preparation for, or in conjunction with: sterilization reversal (male or female); transsexual surgery; sexual dysfunction, in vitro fertilization; or promotion of fertility through extra-coital reproductive technologies.

• Abortion, unless the participant's life would be endangered by continuing the pregnancy, or there is a diagnosed fetal anomaly, or unless the pregnancy is caused by a criminal act such as rape or incest.

• Transplant procedures which BCBSTX considers to be experimental and/or investigational in nature.

• Medical social services, bereavement counseling (except as part of a precertified hospice treatment plan), or vocational counseling.

• Environmental sensitivity, clinical ecology, or inpatient allergy testing or treatment. Chelation therapy except for treatment of acute metal poisoning.

• Prescription drugs or medicines which are covered under a separate prescription drug program with its own limitations and exclusions.

• Acupuncture, videofluroscopy, intersegmental traction, surface EMGs, manipulation under anesthesia, and muscle testing through computerized kinesiology machines such as Isostation, Digital Myograph, and Dynatron.

• Any occupational therapy services that do not consist of traditional physical therapy modalities and are not part of a rehabilitation program designed to restore lost or impaired body functions.

• Any portion of a charge for a service or supply that is in excess of the allowable amount as determined by BCBSTX.

• Any services or supplies not specifically defined as eligible expenses, unless through case management.

• Services or supplies for custodial care as determined by BCBSTX.

• Telemedicine services provided by telephone or fax machine.

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