BluePreferred Virginia: EXCLUSIONS/LIMITATIONS

1. Medical Necessity and Appropriateness. Benefits will not be provided for services, tests, procedures or supplies which we determine are not Medically Necessary for the prevention, diagnosis or treatment of the Member's illness, injury or condition. Although a service or supply is listed as covered, benefits will be provided only if it is medically necessary and appropriate in the Member's particular case. A service or supply is medically necessary and appropriate only if, in our judgment it is:
   
   
   1. Necessary and appropriate for the symptom, diagnosis, prevention or treatment of the Member's illness, injury or condition;
      
      
   2. Consistent with the symptom, diagnosis, prevention or treatment of the Member's illness, injury or condition;
      
      
   3. The most appropriate supply, treatment or level of service that can be provided safely to the Member and, if the Member is an inpatient, cannot be provided safely on an outpatient basis; and
      
      
   4. Not primarily for the convenience of the Member or provider.
      
      
   Services, supplies, and accommodations will not automatically be considered Medically Necessary because they were prescribed by an Eligible Provider. We may consult with professional medical consultants, peer review committees, or other appropriate sources for recommendations on whether the services, supplies, or accommodations a Member receives are Medically Necessary.
   
   
2. Accepted Medical Practice. Benefits will not be provided for any treatment, procedure, facility, equipment, drug, drug usage, device or supply which, in our judgment, is experimental, investigational or not in accordance with accepted medical or psychiatric practices and standards in effect at the time of treatment. A service or supply is deemed to be experimental or investigational if:
   
   
   1. A preponderance of scientific data, such as controlled studies in peer-reviewed journals or literature has not demonstrated that its use results in an improved net health outcome for a specific diagnosis;
      
      
   2. It is not in accordance with generally accepted standards of medical practice; or
      
      
   3. It does not have federal or other required governmental agency approval at the time it is received.
      
      
   4. This exclusion will not be used, however, to deny Patient Cost when the services for Clinical Trials meet all the requirements under the section entitled "Clinical Trial".
      
      
3. Free Care. Payment will not be made for services which, if the Member were not covered under the Group Contract, would have been provided without charge, including any charge or any portion of a charge which, by law, the provider is not permitted to bill or collect from the patient directly.
   
   
4. Routine Care of Feet. Benefits will not be provided for any services related to hygiene and preventative maintenance such as trimming of corns, calluses, flat feet, fallen arches, chronic foot strain or partial removal of a nail without the removal of its matrix, in the absence of an underlying health condition.
   
   
5. Dental Care. Except as otherwise provided, benefits will not be provided for any other type of dental care including extractions, treatment of cavities, care of the gums or bones supporting the teeth, treatment of periodontal abscess, removal of impacted teeth, orthodontia, false teeth or any other dental services or supplies, unless provided in a separate Rider or Endorsement to this Agreement.
   
   
6. Oral Surgery. Except as otherwise provided in the evidence of coverage, benefits will not be provided for procedures involving the teeth or areas surrounding the teeth including the shortening of the mandible or maxillae for cosmetic purposes or for correction of malocclusion are excluded.
   
   
7. Cosmetic Services. Benefits will not be provided for cosmetic surgery (except benefits for Reconstructive Breast Surgery and the treatment of morbid obesity) or other services primarily intended to correct, change or improve appearances. Cosmetic means a service or supply which is provided with the primary intent of improving appearances and not for the purpose of restoring bodily function or correcting deformity resulting from disease, trauma, or previous therapeutic intervention as determined by the Plan.
   
   
8. Prescription Drugs. Except as provided in a separate rider or endorsement to this Agreement, benefits will not be provided for prescription drugs, unless administered to the Member in the course of covered outpatient or inpatient treatment. Take-home prescriptions or medications, including self-administered injections which can be administered by the patient or by an average individual who does not have medical training, or medications which do not medically require administration by or under the direction of a physician are not covered, except as may be provided in a separate rider or endorsement to this Agreement, even though they may be dispensed or administered in a physician or provider office or facility.
   
   
9. Organ Transplants. Organ transplant procedures, including complications resulting from any such procedure, services or supplies related to any such procedure such as, but not limited to, high dose chemotherapy, radiation therapy or any other form of therapy, or immunosuppressive drugs are not covered, except as provided in your Agreement.
   
   
10. Other Exclusions. Benefits will not be provided for the following:
    
    
    1. Services or supplies received before the effective date of your coverage under this Agreement.
       
       
    2. Treatment of sexual dysfunctions or inadequacies except surgical implants for impotence (medical therapy and psychiatric treatment are not covered).
       
       
    3. Any procedure or treatment designed to alter an individual's physical characteristics to those of the opposite sex.
       
       
    4. Weight reduction or obesity treatment, except the surgical treatment of Morbid Obesity.
       
       
    5. Speech therapy, occupational therapy or physical therapy, unless we determine that your condition is subject to improvement. Coverage does not include nonmedical ancillary services such as vocational rehabilitation, employment counseling, or educational therapy.
       
       
    6. Fees and charges relating to fitness programs, weight loss or weight control programs, physical, pulmonary conditioning programs or other programs involving such aspects as exercise, physical conditioning, use of passive or patient-activated exercise equipment or facilities and self-care or self-help training or education. Cardiac rehabilitation programs are covered as described in your Agreement.
       
       
    7. Services or supplies for the medical or surgical treatment of errors of refraction, such as myopia or hyperopia, including but not limited to radial keratotomy or any like or similar procedures or any complications arising therefrom.
       
       
    8. Services to the extent they are covered by any governmental unit, except in Veteran's Administration or armed forces facilities for services received, such as for non-service connected disabilities, for which the recipient is liable. Services or supplies for injuries or diseases related to a covered person's job to the extent the covered person is required to be covered by a workers' compensation law. Services or supplies resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a medical expense payment provision of an automobile insurance policy, excluding no fault insurance.
       
       
    9. Services that are beyond the scope of the license of the provider performing the service.
       
       
    10. Except for covered ambulance services, travel, whether or not recommended by an Eligible Provider.
        
        
    11. Services or supplies for conditions that State or local laws, regulation, ordinances, or similar provisions require to be provided in a public institution.
        
        
    12. Services or supplies received from a dental or medical department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar persons or groups.
        
        
    13. Contraceptive devices.
        
        
    14. Assistive reproductive procedures, except when provided in a separate rider or endorsement to your Agreement.
        
        
    15. Services solely on court order or as a condition of parole or probation unless approved by the Plan.
        
        
    16. Any illness or injury caused by war, declared or undeclared, including armed aggression.
        
        
    17. Any service, supply or procedure which is not specifically listed in your Agreement as a covered benefit.
        
        
    18. Except as otherwise provided in the evidence of coverage, benefits will not be provided for Habilitative Services. Benefits for physical therapy, occupational therapy and speech therapy do not include benefits for Habilitative Services.
        
        

1. Any devices, appliances, supplies, and equipment other than those specified in Section B, of this Rider;
   
   
2. Routine immunizations and boosters such as immunizations for foreign travel, and for work or school related activities;
   
   
3. Prescription Drugs intended solely for cosmetic use;
   
   
4. Prescription Drugs administered by a physician or dispensed in a physician's office;
   
   
5. Drugs, drug therapies or devices that are considered Experimental or Investigative by CareFirst or the FDA;
   
   
6. Drugs or medications lawfully obtained without a prescription such as those that are available in the identical formulation, dosage, form, or strength of a prescription ("Over-the-Counter" medications);
   
   
7. Therapeutic classes where there is a therapeutic equivalent Over-the-Counter product available.
   
   
8. Vitamins, except CareFirst will provide a benefit for Prescription Drug:
   
   
   1. prenatal vitamins;
      
      
   2. fluoride and fluoride containing vitamins; and,
      
      
   3. single entity vitamins, such as Rocaltrol and DHT.
      
      
9. All infertility drugs or agents;
   
   
10. Any portion of a Prescription Drug that exceeds:
    
    
    1. A thirty (30) day supply for non-Maintenance Drugs; or,
       
       
    2. A ninety (90) day supply for Maintenance Drugs;
       
       
11. Prescription Drugs that are dispensed by a nursing home, extended care facility or other such facility for use during a skilled nursing facility inpatient stay.
    
    
12. Appetite suppressants;
    
    
13. Biologicals and allergy extracts; and,
    
    
14. Blood and blood products. Refer to the medical benefits under the Certificate.