The following are Exclusions and Limitations that will help you understand what a health care plan does not include before you enroll. These listings are an overview only. For a comprehensive list of the plans’ exclusions and limitations, you can should request a copy of a Policy/Combined Evidence of Coverage and Disclosure Form (EOC) booklet.

Exclusions and Limitations

• Conditions covered by workers’ compensation or similar law.
• Experimental or investigative services.
• Services provided by a local, state, federal or foreign government, unless you have to pay for them.
• Services or supplies not specifically listed as covered under the Policy/EOC.
• Services received before your effective date or after coverage ends.
• Any services received by Medicare benefits without payment of additional premium.
• Services or supplies that are not medically necessary.
• 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 in the Policy/EOC.
• Any amounts in excess of the maximum amounts listed in the Policy/EOC.
• Sex changes.
• Cosmetic surgery.
• Services primarily for weight reduction except medically necessary treatment of morbid obesity.
• Dental care, dental implants or treatment to the teeth, except as specifically stated in the Policy/EOC.
• Hearing aids.
• Contraceptive drugs and/or certain contraceptive devices, except as specifically stated in the Policy/EOC.
• Infertility services.
• Private duty nursing.
• Eyeglasses or contact lenses, except as specifically stated in the Policy/EOC.
• Vision care including certain eye surgeries to replace glasses, except as specifically stated in the Policy/EOC.
• Mental and nervous disorders and substance abuse, except as specifically stated in the Policy/EOC.
• Certain orthopedic shoes or shoe inserts, except as specifically stated in the Policy/EOC.
• Services or supplies related to a preexisting condition.
• Telephone or facsimile machine consultations.
• Outdoor treatment programs.
• Educational services except as specifically provided or arranged by Anthem Blue Cross.
• Nutritional counseling or food or dietary supplements, except for formulas and special food products to prevent complications of phenylketonuria (PKU).
• Care or treatment furnished in a non-contracting hospital, except as specifically stated in the Policy/EOC.
• Personal comfort items.
• Custodial care.
• Certain genetic testing.
• Outpatient speech therapy, except as specifically stated in the Policy/EOC.
• Any amounts in excess of maximums stated in the Policy/EOC.
• Outpatient drugs, medications or other substances dispensed or administered in any outpatient setting.
• Services or supplies provided to any person not covered under the Agreement in connection with a surrogate pregnancy.