BlueEdge HSA Plans


Blue Cross BlueShield of Illinois
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BlueEdge HSA Plans

BlueEdge HSA Overview

 

BlueEdge HSA Overview

BlueEdge Individual HSA and BlueEdge Individual HSA 5000 plans are priced among the lowest of Blue Cross Blue Shield of Illinois’ major medical health insurance plans, while still covering the same health care services as the more expensive PPO plans. BlueEdge high deductible health plans offer reliable coverage and affordable monthly premiums.

BlueEdge HSA

Key coverage and plan features include:

  • Unlimited first dollar coverage for Preventive Adult and Child Care services at no cost (as mandated by law)
  • Prescription drug coverage (counts toward the deductible)
  • Diagnostic testing
  • Hospital services
  • Select the participating provider coverage level that fits your budget — 100% or 80%
  • Choice of several deductible levels
  • Optional dental coverage

Blue Cross Blue Shield of Illinois HSA Plans

BlueEdge Individual HSAs are a good fit for:

  • Individuals who want affordable premiums and a wide range of benefits and don’t expect a lot of medical expenses (i.e. Comprehensive Catastrophic Coverage)
  • Self-employed individuals who welcome affordable, reliable benefits and the ability to save and invest with their HSA. You may also be able to deduct your premiums.
  • Professionals looking for tax-advantage savings channels that can be used for qualified medical expenses.
  • Healthy individuals and families who appreciate the affordability and who are not as likely to have huge medical expenses associated with major illnesses; catastrophic coverage is especially important.
  • Small employers (less than 10 employees) looking for a way to help their employees affordably self-insure.
  • Working uninsured seeking lower premiums, reliable benefits and the “ownership” of their HSA; catastrophic coverage is especially important to these individuals.
  • Early retirees who are able to roll over their HSA and use tax-advantaged dollars to pay for health care expenses in their retirement. If they are between the ages of 55 and 64, they can make catch-up contributions to their HSA.

Network

All BlueEdge Individual HSA plan options utilize the extensive Blue Cross and Blue Shield of Illinois PPO network (including over 90% of Illinois physicians), and provide nationwide PPO access through the Blue Card Program, which represents the combined PPO networks of the United State’s Blue Cross and Blue Shield plans. This provides a comprehensive network of doctors and hospitals to individuals traveling outside of Illinois. Blue Cross and Blue Shield of Illinois BlueEdge HSA plan members also pay less for health care services because of the deeply discount fees BCBSIL has negotiated with participating providers.

HSA Administration Options

Blue Healthcare Bank

When you purchase HSA-compatible coverage from Blue Cross and Blue Shield of Illinois, you can choose any financial institution to establish your HSA. Blue Cross and Blue Shield of Illinois offers HSA services through Blue Healthcare Bank, an independent licensee of the Blue Cross and Blue Shield Association created by 33 investing Blue Cross and Blue Shield Plans. Health Care Services Corporation, the parent company of Blue Cross Blue Shield of Illinois, is one of the Blue Cross Blue Shield Plans with an ownership stake in Blue Healthcare Bank.

On the Blue Cross Blue Shield of Illinois HSA application, you have the option of establishing a Blue Healthcare Bank HSA. If you choose this option, Blue Healthcare Bank charges a one-time account set-up fee of $16 and a $3.50 monthly maintenance fee for balances under $2,000 and a $.50 monthly maintenance fee for balances $2,000 or greater.

First American Bank

To avoid monthly maintenance fees and minimum balance requirements, we recommend opening an HSA account with First American Bank and electing to receive your bank statements online. They provide a free debit card for your HSA account and have branches throughout the Chicagoland area. However, if you elect to receive paper bank statements, a $3.00 monthly fee is charged unless you maintain a minimum average daily balance of $2000.

BlueEdge HSA Individual and Family Plans

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BlueEdge Individual HSA

Our Rating: BlueEdge HSA Plans

BlueEdge Individual HSA plans offer a 100% or 80% coinsurance option and a choice of 5 deductibles: $1,250, $1,750, $2,600, $3,500, and $5,000 for individuals; and $2,500, $3,500, $5,200, $7,000, and $10,000 for families.

BlueEdge HSA Deductibles
  • $1,250 single / $2,500 family
  • $1,750 single / $3,500 family
  • $2,600 single / $5,200 family
  • $3,500 single / $7,000 family
  • $5,000 single / $10,000 family

With the 100% coinsurance option, members pay nothing for covered services after the deductible is met. With the 80% coinsurance option, members only pay the remaining 20 percent for covered services once their deductible has been met when they use participating doctors and hospitals. Once the amount paid in coinsurance reaches $3,000, all covered services will be paid at 100 percent when participating doctors and hospitals are used.

BlueEdge Individual HSA 5000

Our Rating: BlueEdge HSA Plans

The BlueEdge Individual HSA 5000 annual deductible for individuals is $5,000; the family deductible is $10,000. BlueEdge Individual HSA 5000 covers 100% of preventive care visits without having to reach your deductible and 100 percent of out-of-pocket expenses once the plan deductible has been met. This means you pay nothing for preventive check-ups, routine screenings, OBGYN visits, mammograms, and blood work. For non-preventive covered services, you pay nothing and are covered at 100% once your annual deductible has been met when using participating doctors and hospitals.

BlueEdge Individual HSA 5000 is a good plan for individuals who are relatively young with a good health history because they are unlikely to incur high health care expenses in any given year and will benefit from lower monthly premiums and free preventive care.

Individuals who are willing to pay a little more for their monthly premiums in return for a lower annual deductible may want to consider a BlueEdge Individual HSA plan with a lower deductible.

BlueEdge HSA Plans

BlueEdge HSASM Comparison

 

Benefit HighlightBlueEdge HSASMBlueEdge HSA 5000SM
NetworkBCBSIL PPO Network
Include over 90% of IL doctors and 200 IL hospitals
Deductible
$1,250 single / $2,500 family
$1,750 single/ $3,500 family
$2,600 single/ $5,200 family
$3,500 single / $7,000 family
$5,000 single / $10,000 family
Individual Out-of-Pocket Expense LimitAnnual deductible plus $3,0001Annual $5,000 deductible
Preventive Care Services
(benefits covered as defined by national guidelines)
100%
(Unlimited preventive care benefits before having to reach deductible)
100%
(Unlimited preventive care benefits before having to reach deductible)
CoinsuranceYou pay 0% or 20%You pay 0%
Optional Maternity CoverageCoinsuranceYou pay 0% or 20%You pay 0%
Prescription DrugsYou pay 0% or 20%You pay 0%
The information in the Outline of Coverage does not incorporate changes mandated by the Affordable Care Act of 2010 and is not reflective of the final benefits for products with an October 1, 2010, or later effective date. Please view the Important Notice Regarding Your Benefits for additional information regarding Affordable Care Act benefits.
Outline of Coverage BlueEdge HSA PlansOutline of Coverage BlueEdge HSA Plans
Important Notice Regarding Your BenefitsImportant Notice Regarding Your Benefits BlueEdge HSA Plans

1. Benefits reduced when non-participating providers are used. This is a summary of highlights only. Please refer to the Outline of Coverage for each plan for additional details.

 

BlueEdge HSA Plans

BlueEdge HSA – Outline of Coverage

 

Plan FeatureIn-NetworkOut-of-Network
PPO NetworkBlueCross and BlueShield of Illinois PPO NetworkN/A
Lifetime Maximum BenefitUnlimited
Deductible
Per calendar year
$1,250 per individual / $2,500 per family1
$1,750 per individual / $3,500 per family1
$2,600 per individual / $5,200 per family1
$3,500 per individual / $7,000 per family1
Hospital Admission Deductible
Per admission, per individual
$0$3001
Coinsurance
The level of coverage provided by the plan after the calendar year Deductible has been satisfied.You must select from two levels of participating provider coverage:

  • 100% partipating provider coverage
  • 80% partipating provider coverage
100%
80%
80%
60%
Out-of-Pocket Expense Limit
The amount of money an individual pays toward covered hospital and medical expenses during any one calendar year.
Deductible + $3,0002Deductible + $6,000
Family Out-of-Pocket Expense LimitDeductible + $6,0002Deductible + $12,000
Inpatient/Outpatient Physician Medical/Surgical100% or 80%80% or 60%
Wellness Care
From age 16. Covers services associated with both an annual physical exam and an annual gynecological exam. Includes immunizations and routine diagnostic tests received or ordered on the same day as the exam.
100% (deductible waived)80% or 60%
Well-Child Care
To age 16. Includes immunizations, physical exams and routine diagnostic tests.
100% (deductible waived)80% or 60%
Inpatient/Outpatient Hospital Services
Includes surgery, pre-admission testing and services received in a skilled nursing facility, coordinated home care program and hospice. (For mental health coverage levels please refer to mental health benefits.)
100% or 80%80% or 60%
Inpatient/Outpatient Hospital Diagnostic Testing
Includes, but not limited to, X-rays, lab tests, EKGs ECGs, pathology services, preliminary function studies, radioisotope tests, and electromyograms
100% or 80%80% or 60%
Physical, Occupational, and Speech Therapist
($3,000 maximum per therapy, per calendar year)
100% or 80%80% or 60%
Temporomandibular Joint Dysfunction and Related Disorders
($1,000 lifetime maximum)
100% or 80%80% or 60%
Muscle Manipulations Rendered by a Physician or Chiropractor
($1,000 per calendar year)
100% or 80%80% or 60%
Optional Maternity Coverage
Inpatient/Outpatient Hospital services and Physician Medical/Surgical services.When elected, maternity benefits will begin 365 days after the effective date of the maternity coverage.
100% or 80%80% or 60%
Outpatient Emergency Care (Accident or Illness)
For both Hospital and Physician
100% or 80%
Additional Surgical Opinion Program
Following a recommendation for elective surgery, provides additional consultations and related diagnostic service by a Physician, as needed.
100% or 80%
Other Covered Services
Ambulance services; durable medical equipment; services of a private duty nursing service ($1,000 per month maximum1); naprapathic services rendered by a Naprapath ($1,000 per calendar year maximum1); artificial limbs and other prosthetic devices; oxygen and its administration; blood plasma; leg, arm and neck braces; surgical dressings; casts and splints
100% or 80%
Mental Illness Treatment and Substance Abuse Rehabilitation Treatment3
Inpatient Care
(30 Inpatient Hospital days per calendar year)
Physician100% or 80%80% or 60%
Hospital (first 14 days)60%50%
Hospital (after 14 days)50%50%
Outpatient Care
(30 visits per calendar year combined annual maximum and 100 visits per lifetime maximum))
Physician and Hospital50%50%
Medical Services Advisory (MSA3)
In order to maximize your benefits, the Policyholder is responsible for notifying the MSA for Hospital admissions at Non-Participating and Non-Plan Hospitals. (MSA notification by the Policyholder is NOT required when services are rendered in a Participating Hospital.) MSA notification is required within three business days for non-emergencies and within one business day for emergencies and maternity admissions. Failure to contact the MSA will result in a reduction of Hospital benefits of $1,000.Mental Health Unit
In order to maximize your benefits, the Policyholder is responsible for notifying the Mental Health Unit for ALL care related to mental health and substance abuse. In the event of an admission, for either mental illness or substance abuse, notification is required three days prior for non-emergencies and within 24 hours or as soon as reasonably possible for emergencies. If Policyholder does not notify the Mental Health Unit, the Policyholder will then be responsible for the first $1,000 or 50% of the Hospital charge, whichever is less.

 

Outpatient Prescription Drug BenefitYou PayBlueEdge HSA Pays
Retail Pharmacy0%4 or 20%4100%4 or 80%4

 

Benefits for covered services are provided at either the Eligible Charge or the Maximum Allowance. Consult the Policy for definitions and your financial responsibility.
1 The deductible amount will be adjusted automatically if the amount is lower than the amount required by law.
2 The individual out-of-pocket expense plus individual deductible can not exceed $5,000. The family aggregate out-of-pocket expense plus family deductible can not exceed $10,000.
3 Does not apply to out-of-pocket limit.
4 After the deductible is met. When filling prescriptions before reaching your deductible, you will receive a negotiated discount on your prescriptions. Prescription expenses count towards the deductible.
IF USING A NON-PLAN PROVIDER…
A $300 per Hospital admission Deductible will apply.* If using a Non-Plan Provider, benefit are reduced to 50%. However, with the exception of alcoholism, no benefits are available for Substance Abuse Rehabilitation Treatment. Also, Outpatient Hospital and Physician emergency care, and additional surgical opinions are paid at 100%, regardless of the coverage level or Provider selected.PRE-EXISTING CONDITIONS LIMITATION
Pre-existing Conditions are those health conditions which were diagnosed or treated by a Provider during the 12 months prior to the coverage effective date, or for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis or treatment. Any Pre-existing Condition will be subject to a waiting period of 365 days.

PREMIUMS
Blue Cross Blue Shield of Illinois may change premium rates only if they do so on a class basis for all DB-43 HCSC policies. Premiums can be changed based on age, sex, and rating area.

GUARANTEED RENEWABILITY
Coverage under this Policy will be terminated for non-payment of premium. Blue Cross Blue Shield of Illinois can refuse to renew this Policy only for the following reasons:

A. If all Policies bearing form number DB-43 HCSC are not renewed, written notice will be provided at least 90 days before coverage is discontinued. Furthermore, you may convert to any other individual policy Blue Cross Blue Shield of Illinois offer to the individual market.
B. In the event of fraud or an intentional misrepresentation of material fact under the terms of the coverage, written notice will be given at least 30 days before coverage is discontinued.

Hospitalization, Services, and supplies which are not Medically Necessary; Services or supplies that are not specifically mentioned in this Policy; Services or supplies for any illness or injury arising out of or in the course of employment for which benefits are available under any Workers’ Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits except where not required by law; Services or supplies that are furnished to you by the local, state, or federal government; Services and supplies for any illness or injury occurring on or after your Coverage Date as a result of war or an act of war; Services or supplies that do not meet accepted standards of medical or dental practice; Investigational Services and Supplies, including all related services and supplies; Custodial Care Service; Routine physical examinations, unless specifically stated in this Policy; Services or supplies received during an Inpatient stay when the stay is primarily related to behavioral, social maladjustment, lack of discipline, or other antisocial actions which are not specifically the result of Mental Illness; Cosmetic Surgery and related services and supplies, except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases; Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar coverage; Charges for failure to keep a scheduled visit or charges for completion of a Claim form; Personal hygiene, comfort, or convenience items commonly used for other than medical purposes, such as air conditioners, humidifiers, physical fitness equipment, televisions, and telephones; Special braces, splints, specialized equipment, appliances, ambulatory apparatus, battery controlled implants, except as specifically mentioned in this Policy; Eyeglasses, contact lenses, or cataract lenses and the examinations for prescribing or fitting of glasses or contact lenses or for determining the refractive state of the eye, except as specifically mentioned in this Policy; Treatment of flat foot conditions and the prescription of supportive devices for such conditions and the treatment of subluxations of the foot or routine foot care; Immunizations, unless otherwise stated in this Policy; Maintenance Occupational Therapy, Maintenance Physical Therapy, and Maintenance Speech Therapy; Speech Therapy when rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome), attention disorder, conceptual handicap, or mental retardation; Hearing aids or examinations for the prescription or fitting of hearing aids; Diagnostic Service as part of routine physical examinations or check-ups, premarital examinations, determination of the refractive errors of the eyes, auditory problems, surveys, case finding, research studies, screening, or similar procedures and studies, or tests which are Investigational, unless otherwise specified in this Policy; Procurement or use of prosthetic devices, special appliances, and surgical implants which are for cosmetic purposes, or unrelated to the treatment of a disease or injury; Services and supplies provided for the diagnosis and/or treatment of infertility including, but not limited to, Hospital services, Medical Care ,therapeutic injection, fertility and other drugs, Surgery, artificial insemination, and all forms of in-vitro fertilization; Maternity Service, including related services and supplies, unless selected as an option (Complications of Pregnancy are covered as any other illness); Long Term Care; Inpatient Private Duty Nursing Service; Maintenance Care; Wigs (also referred to as cranial prothesis); and services and supplies rendered or provided for human organ or tissue transplants other than those specifically named in this policy.
READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!

BlueEdge HSA Plans

BlueEdge HSA 5000

Overview

The BlueEdge Individual HSA 5000 is a good plan for individuals who are relatively young with a good health history because they are unlikely to incur high health care expenses in any given year and will benefit from lower monthly premiums and free preventive care. The annual deductible for individuals is $5,000 and the family deductible is $10,000, shared between all covered family members.

First Dollar Preventive Care Benefits

BlueEdge Individual HSA 5000 covers 100% of preventive care visits without having to reach your deductible and 100% of out-of-pocket expenses once the plan deductible has been met. This means you pay nothing for preventive check-ups, routine screenings, OBGYN visits, mammograms, and blood work. For non-preventive covered services, you pay nothing and are covered at 100% once your annual deductible has been met when using participating BCBSIL doctors and hospitals.

Individuals who are willing to pay a little more for their monthly premiums in return for a lower annual deductible may want to consider a BlueEdge Individual HSA plan with a lower deductible.

BlueEdge HSA 5000 – Benefit Summary
Plan FeatureIn-NetworkOut-of-Network
PPO NetworkBlueCross and BlueShield of Illinois PPO NetworkN/A
Lifetime Maximum BenefitUnlimited
Deductible
Per calendar year
$5,000 per individual / $10,000 per family1
Hospital Admission Deductible
Per admission, per individual
$0$3001
Coinsurance
The level of coverage provided by the plan after the calendar year Deductible has been satisfied.
100%80%
Out-of-Pocket Expense Limit
The amount of money an individual pays toward covered hospital and medical expenses during any one calendar year.
Your annual deductible ($5,000)Your annual deductible ($5,000) + additional $5,000
Family Out-of-Pocket Expense LimitYour annual deductible ($10,000)Your annual deductible ($10,000) + additional $10,000
Inpatient/Outpatient Physician Medical/Surgical100%80%
Wellness Care
From age 16. Covers services associated with both an annual physical exam and an annual gynecological exam. Includes immunizations and routine diagnostic tests received or ordered on the same day as the exam.
100% after $20 copay (deductible waived)80%
Well-Child Care
To age 16. Includes immunizations, physical exams and routine diagnostic tests.
100% after $20 copay (deductible waived)80%
Inpatient/Outpatient Hospital Services
Includes surgery, pre-admission testing and services received in a skilled nursing facility, coordinated home care program and hospice. (For mental health coverage levels please refer to mental health benefits.)
100%80%
Inpatient/Outpatient Hospital Diagnostic Testing
Includes, but not limited to, X-rays, lab tests, EKGs ECGs, pathology services, preliminary function studies, radioisotope tests, and electromyograms
100%80%
Physical, Occupational, and Speech Therapist
($3,000 maximum per therapy, per calendar year)
100%80%
Temporomandibular Joint Dysfunction and Related Disorders
($1,000 lifetime maximum)
100%80%
Muscle Manipulations Rendered by a Physician or Chiropractor
($1,000 per calendar year)
100%80%
Optional Maternity Coverage
Inpatient/Outpatient Hospital services and Physician Medical/Surgical services.

When elected, maternity benefits will begin 365 days after the effective date of the maternity coverage.

100%80%
Outpatient Emergency Care (Accident or Illness)
For both Hospital and Physician
100%
Additional Surgical Opinion Program
Following a recommendation for elective surgery, provides additional consultations and related diagnostic service by a Physician, as needed.
100%
Other Covered Services
Ambulance services; durable medical equipment; services of a private duty nursing service ($1,000 per month maximum1); naprapathic services rendered by a Naprapath ($1,000 per calendar year maximum1); artificial limbs and other prosthetic devices; oxygen and its administration; blood plasma; leg, arm and neck braces; surgical dressings; casts and splints
100%
Mental Illness Treatment and Substance Abuse Rehabilitation Treatment3
Inpatient Care
(30 Inpatient Hospital days per calendar year)
Physician100%80%
Hospital (first 14 days)100%50%
Hospital (after 14 days)100%50%
Outpatient Care
(30 visits per calendar year combined annual maximum and 100 visits per lifetime maximum))
Physician and Hospital100%50%
Medical Services Advisory (MSA1)
In order to maximize your benefits, the Policyholder is responsible for notifying the MSA for Hospital admissions at Non-Participating and Non-Plan Hospitals. (MSA notification by the Policyholder is NOT required when services are rendered in a Participating Hospital.) MSA notification is required within three business days for non-emergencies and within one business day for emergencies and maternity admissions. Failure to contact the MSA will result in a reduction of Hospital benefits of $1,000.

Mental Health Unit
In order to maximize your benefits, the Policyholder is responsible for notifying the Mental Health Unit for ALL care related to mental health and substance abuse. In the event of an admission, for either mental illness or substance abuse, notification is required three days prior for non-emergencies and within 24 hours or as soon as reasonably possible for emergencies. If Policyholder does not notify the Mental Health Unit, the Policyholder will then be responsible for the first $1,000 or 50% of the Hospital charge, whichever is less.

 

Outpatient Prescription Drug BenefitYou PayBlueEdge HSA 5000 Pays
Retail Pharmacy0%4100%4

 

Benefits for covered services are provided at either the Eligible Charge or the Maximum Allowance. Consult the Policy for definitions and your financial responsibility.
1 The deductible amount will be adjusted automatically if the amount is lower than the amount required by law.
2 The individual out-of-pocket expense plus individual deductible can not exceed $5,000. The family aggregate out-of-pocket expense plus family deductible can not exceed $10,000.
3 Does not apply to out-of-pocket limit.
4 After the deductible is met. When filling prescriptions before reaching your deductible, you will receive a negotiated discount on your prescriptions. Prescription expenses count towards the deductible.
IF USING A NON-PLAN PROVIDER…
A $300 per Hospital admission Deductible will apply.* If using a Non-Plan Provider, benefit are reduced to 50%. However, with the exception of alcoholism, no benefits are available for Substance Abuse Rehabilitation Treatment. Also, Outpatient Hospital and Physician emergency care, and additional surgical opinions are paid at 100%, regardless of the coverage level or Provider selected.

PRE-EXISTING CONDITIONS LIMITATION
Pre-existing Conditions are those health conditions which were diagnosed or treated by a Provider during the 12 months prior to the coverage effective date, or for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis or treatment. Any Pre-existing Condition will be subject to a waiting period of 365 days.

PREMIUMS
Blue Cross Blue Shield of Illinois may change premium rates only if they do so on a class basis for all DB-43 HCSC policies. Premiums can be changed based on age, sex, and rating area.

GUARANTEED RENEWABILITY
Coverage under this Policy will be terminated for non-payment of premium. Blue Cross Blue Shield of Illinois can refuse to renew this Policy only for the following reasons:

A. If all Policies bearing form number DB-43 HCSC are not renewed, written notice will be provided at least 90 days before coverage is discontinued. Furthermore, you may convert to any other individual policy Blue Cross Blue Shield of Illinois offer to the individual market.
B. In the event of fraud or an intentional misrepresentation of material fact under the terms of the coverage, written notice will be given at least 30 days before coverage is discontinued.

Hospitalization, Services, and supplies which are not Medically Necessary; Services or supplies that are not specifically mentioned in this Policy; Services or supplies for any illness or injury arising out of or in the course of employment for which benefits are available under any Workers’ Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits except where not required by law; Services or supplies that are furnished to you by the local, state, or federal government; Services and supplies for any illness or injury occurring on or after your Coverage Date as a result of war or an act of war; Services or supplies that do not meet accepted standards of medical or dental practice; Investigational Services and Supplies, including all related services and supplies; Custodial Care Service; Routine physical examinations, unless specifically stated in this Policy; Services or supplies received during an Inpatient stay when the stay is primarily related to behavioral, social maladjustment, lack of discipline, or other antisocial actions which are not specifically the result of Mental Illness; Cosmetic Surgery and related services and supplies, except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors, or diseases; Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar coverage; Charges for failure to keep a scheduled visit or charges for completion of a Claim form; Personal hygiene, comfort, or convenience items commonly used for other than medical purposes, such as air conditioners, humidifiers, physical fitness equipment, televisions, and telephones; Special braces, splints, specialized equipment, appliances, ambulatory apparatus, battery controlled implants, except as specifically mentioned in this Policy; Eyeglasses, contact lenses, or cataract lenses and the examinations for prescribing or fitting of glasses or contact lenses or for determining the refractive state of the eye, except as specifically mentioned in this Policy; Treatment of flat foot conditions and the prescription of supportive devices for such conditions and the treatment of subluxations of the foot or routine foot care; Immunizations, unless otherwise stated in this Policy; Maintenance Occupational Therapy, Maintenance Physical Therapy, and Maintenance Speech Therapy; Speech Therapy when rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome), attention disorder, conceptual handicap, or mental retardation; Hearing aids or examinations for the prescription or fitting of hearing aids; Diagnostic Service as part of routine physical examinations or check-ups, premarital examinations, determination of the refractive errors of the eyes, auditory problems, surveys, case finding, research studies, screening, or similar procedures and studies, or tests which are Investigational, unless otherwise specified in this Policy; Procurement or use of prosthetic devices, special appliances, and surgical implants which are for cosmetic purposes, or unrelated to the treatment of a disease or injury; Services and supplies provided for the diagnosis and/or treatment of infertility including, but not limited to, Hospital services, Medical Care ,therapeutic injection, fertility and other drugs, Surgery, artificial insemination, and all forms of in-vitro fertilization; Maternity Service, including related services and supplies, unless selected as an option (Complications of Pregnancy are covered as any other illness); Long Term Care; Inpatient Private Duty Nursing Service; Maintenance Care; Wigs (also referred to as cranial prothesis); and services and supplies rendered or provided for human organ or tissue transplants other than those specifically named in this policy.
READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!